HomeMy WebLinkAboutSeptic Pumping Slip - 657 FOREST STREET 6/11/2018 Commonweptith of Massachuseffs RECEIVED
own of �SyMem Pumping.Record 04 OF*NOM ANDOVER
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®EP has provided this form for use-by local Boards of Health. Other forms may be'used,but the
informations must be substantially the tame as that provided here. Before using.this form,check with your
local Board of Health to determine the forth they use. The System Pumping Record must be submitted to
the kcal ward of Health or other approving authority.
1. System Location: Left/Right front of house, Left/Right rear of house, Left/r t side o�houeft/
Dight side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address 0 � V69
City/Town State Zip Code
2. System Owner: �
' iVama'
Address(if different from location)
Citylrown ' '. State-;..-- � Zi Godg
Telephone Number
.B. Pumping uJ p ii Record
--,
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of systerrf: Cesspool(s) eptle Tank ❑ Tight Tank t.
❑ Other(describe):
4. Effluent Tee Filter present? es ® No If yes, was it cleaned? ❑ s El No,
' 5. Condition of System• ���..,;� �� �'` c✓ P
6: System ped By:
Pfeil.Bateson ' x~5821
Mame Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location ere contents-were disposed:
.� Lowell Waste Water
Sign a Hhule Date
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