HomeMy WebLinkAboutSeptic Pumping Slip - 102 LOST POND LANE 7/2/2018 Commonwelalthof Massachusefts RECEIVED
Cjt�/Town of
eSpMem Pumpift.Record TOWN 01; i ANDOVER
CEP ha's provided this form for use-by local Boards 6f,Health. Other forms maybe bsed,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 forth they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. FaciRy. Infor Mation
1, System Location: Left/Right front of Mouse, Left/Right rear of hausC
Heft/rJ h i e of ho se;LeftRight side of building, Left/Right front of building, Left/Right rear(ifi mg, Un er �pk
Andress y .
cityirown State Zip Cade
Z. System tJwner: IT
VIA-
Name'
Address Of different from location)
CiWTown statez' e i ode
f 07
Telephone Number r
B. u ;nRpcord
0
1. bate of Pumping date 2. Quantity pumped:
Gallans--. —��
3. Type-of system: El Cesspool(s) eptic Tank El Tight Tank
❑ father(describe):
4. Effluent Tee Filter present? Yes o If yes, was 4t cleaned? ® Yes El No,
5. Condition of System: /
tca
. .
.V\jg_e,�
6. System Pumped By.,
Neil-Bateson F5621
Name Vehicle Lttoense Number
Bateson Enterprises Inc
Company
7. Lopato contents,were disposed:
G S: Lowell Waste Water
Sign a Mauls Cate ...""
t5form4.doc-06/03 System Pumping Record•page 1 of 1