HomeMy WebLinkAbout- Septic Pumping Slip - 66 CEDAR LANE 10/31/2018 ,f_ Z\_ Commonwealth of Massachusetts
City/Town of RECEIVED
System Pumping Record JM 3 2018
Fonn 4 TOM4 OF NOKI'H ANDOVER
HAff�DEPARTMENT
CEP has provided this form for use�by local Boards of�Health. Other forms maybe
%Se but the
Information-must be substantially the Game 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. Factility Inform' sition
I. System Location: Leh/Right front of house, Left/Right rear of house )ht:ffid_i__ hP99"g,Left I
Right side of building, Left/Right front of building, Left/Right rear of bu 16 g, Un dec Address
01wrown state zip Cotle
2'. System Owner V\,e
Name*
Address(if different from location)
City/Town State Zip Code
Telephone Number
Pumping ftecord
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system: E] Cesspool(s) 03-8901—oTank El Tight Tank
[I Other(describe):
4. Effluent Tee Filter present.? El Yes If yes, was it cleaned? Ej Yes E] No
5. Condition of System-
6. System Pumped By:
Nell.Bates*bn F5821
Name Vehicle License Number
Bateson Enterprises Inc`
Company
7, L h e contents-were disposed:
77S:
Lowell Waste Water
Date
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