HomeMy WebLinkAbout- Septic Pumping Slip - 177 CARLTON LANE 10/31/2018 Commonwealth of Massachusetts RECENED
City/Town of
0 CT 3 12 0 18
System Pumping Record
Form 4 TOWN OF NOMH ANDOVER
HEALM DEPARTMEW
DEP has provided this form for use-by local Boards of Health. Other forms May rbe'used,but the
information,must be substantially the tame as that provided here. Before using.Ws 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. Facift Inforiffl' ation
1. System Location: Left/Right front of house, Left/Right rear of house, Left./&JAi:aid oqfh§�� Left
,(
U ti r 8---
Right side of building, Left Right front of building, Left/Right rear of building, Unaer deqX
Address 'T7 H�_YNI LV\-
City/Town state Zip Code
2. System Owner
Name'
Address(if different from eocafian)
CiWown Stater AZip Code
Telephone Number
.B. Pumping ftecord
1. Date of Pumping Date 2. Quiantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) Septic Tank El Tight Tank
[I Other(describe):
4. Effluent Tee Filter present.? El Yes If yes, was it cleaned? E] Yes No
5. Condition of System:
6. System Pumped By:
Nell.BatesTon F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Locati ij�,.7contents-were disposed:
7071'es' 'D - Lowell Waste Water
—Sign Haulee
v W mete
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