HomeMy WebLinkAboutSeptic Pumping Slip - 30 SUGARCANE LANE 5/1/2018 Commonwealth ® l� RIVED
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wCity/Town of MAY 01 01
SyMem Pumping-Record TOWN OF RTI-1 ANDOVER
DEP has provided this form'for use-by local Boards of Health.tither forms maybe•used,but the
information-must be substantially the same as that provided here. Before using.this form,check with your
local Board of Health to determine the forrh they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Inform' ation
9. System Location: Left Mvaqront of hou_s , Left/Right rear of house, Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address r �
Cityfrown estate Zip Code
2, System Owner: c
• Name'
Address(if different from location)
Ci own ' stater Z11 Zip Code
Telephone Number
in
1. bate of Pumping nate 2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
® Other(describe):
4. Effluent Tee Filter present? Yep No If yes,was it cleaned? ❑ Yes ❑ No.
' S. Condition of System• `1
y._AYA
6: System Pumped By:
Nell,Bateson F6821
Name Vehicle License Number
Bateson Enterprises Inc,
Company
7. Lo • °n-woere contents-were disposed:
C 5 Lowell Waste Water
c -fet
' d
sign @ Thule Date
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