HomeMy WebLinkAboutSeptic Pumping Slip - 34 RALEIGH TAVERN LANE 8/15/2018 Commonwealthof Massachuseffs
Ciwn of RECEIVED
tem Pumping.
FormIMN OF NO RUH'
ANDOVER
DEP has provided this form`for use-by local Boards of Health. Other forms mayEbt .d° tq hl
information'must be subst6nfially the tame as that provided here. Before using.this fora:,check with your
loca'I 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. Factoty. Inforriafion
I. System Location: Left/Right front of house, Left/Right rear of hour.e, Left flht d of hou" Left
Right side of building, Left/Right front of building, Left I Right rear of building, Un er r k
Address � `�. �,�, `l/4, •��^'G��",Q-.�'`rf'� ��(,.�''Y�4 ,,�- -.
Gitylrourn Sfate Zip code
2. System Owner
Name'
Address(if different from location)
CityCtown Stat ° ,.� c� � �Zip Coda ,
t 'telephone Number
• r y
1`r
4. Date of Pumping �. %Au nfi Pumped:
Date Gallons
3. Type-of system: ® Cesspool(s) eS ptic Tank Tight Tank
Other(describe):
4. Effluent Tee Filter present? es 0 No If yes, was it cleaned? s Ej Na
' S. Condition of System:
e
6. System umped By:
Neil.Batesion ' F5321
Name Vehicle License Number
Bateson Erltel�rises Inc'
Company
7. Locatio e contents-were disposed:
S Lowell Waste Water
M
Sign a Fiaufe L1ate
Mrm4,doc-08/03 System Pumping Record.Page 1 of 1