HomeMy WebLinkAboutSeptic Pumping Slip - 76 GRANVILLE LANE 7/2/2018 Commonwealth of Massachusetts ���°°CE I
UwTown of s d d 1
" s System Pump►11' §t Record OVJ OFF NORT�4ANDOVER
". Form 4
DEP has provided this fora for use-by local Boards of Health. Other form's may be'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. Faci , information
1. System Location: Left/Right front of Mouse, Left Mg6t
ear of house eft/right side of house, Left
Right side of building, Left/Right front of bulidirig, g rear of building, Under deck
• Address I �j�``c���, `�e.. �..-�✓�..� ��sV'��'�,. � ,.� `
cifylrown State Zip Code
2. system Owner.
• Name
Address(if different from location)
State _ Zip Code
CWTown �- I
P Telephone Number r �,
B. Opolp►'ing Rpeord
1, Date of Pumping Date 2• QuanUty Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
[] other(describe):
4. Effluent Tee Filter present? ❑ Yes [�J� If yes,was it cleaned? [j Yes C] No,
' 5. Condition of System: 1 Q v��{1 z✓� -
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatio here content were disposed:
Lowell Waste Water
sign a Haul 7 Bate
15form4.doo•06/03 system Pumping Record•Page 1 of 1