HomeMy WebLinkAbout- Septic Pumping Slip - 26 SHANNON LANE 10/19/2018 wealth of Massachusetts
Common
Cit�/Town of
ANDovER
y r Pumping,Record 1 t t�tc��14 PA TMEt
®EP has provided this form'for use-by local Boards of Health. Other forms 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 form they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility InforMation. l
1. System Location: L /Ftight front of pious eft,Bight of� ouseileft/right side of house, Left/
�~ mm
Right side of building, Left 1 Right front of building, Left/Right rear of building, Under deck
Address n 4
zit i/Town state Zip Code
2. System owner
- ` I
Name'
' Address(if different from toaation)
Cityfrown P Stater en � �-., ,Zip Code
'telephone Number
® PuMpIng Rpcord .
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system': ❑ Cesspool(s) eptic Tank ❑ Tight Tank
Other(describe):
4.. Effluent Tee Filter present? ❑ Yeso !f yes,was it cleaned? [� Yes No,
5. Condition ofaystem: ,
6. System Pumped By:
Nell.Satescrn - F5821
Name Vehicle License Number
6ateson Ehter'prises Ina
Company
7. Location where-� ontents-were disposed:
.L ' Lowell Waste Water
to
Sign Crate
tftrm4.doc-06/03 System pumping Record d page 1 of 1