HomeMy WebLinkAbout- Septic Pumping Slip - 36 HAWKINS LANE 10/31/2018 REC-41,�,=-IVIEDhi
Commonwealth of Massachusetts
CityfTown of 0C[ 312-('08
System Pumpling Record
(')F�CRTH ANDOVE-R
Form 4 HEALT11�)U'ARTMSJ
DEP has provided this form for use-by local Boards of Health. Other forms maybe used,but the
information-must be substantially the tame as that provided here. Before using.this form,check with your
local Board of Health to determine the form they use. The$ystem Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Factility InforMation
1. System Location: Left %�igi:f:r-q o ligh _:n-t—p-f-h—o`us-d Q t _p Left/Right rear of house, Left/right side of house, Left I
Leff�Rig
�
Right side of building, R ron of�uildlfig, Left/Right rear of building, Under deck
Address
,f fi
cityrrown State Zip Code
2. System Owner
Name'
Address(if different from location)
City/Town Stater Zip Co de
Teleih-o-n-e-Mumber
.B. Pumping Record
9. Date of Pumping Date/ u6nfity Pumped: Gallons
7
3. Type-of system: 0 Cesspool(s) Septic Tank 0 Tight Tank
0 Other(describe):
4. Effluent Tee Filter present? [] Yes No If yes, was it cleaned? Ej Yes E] No
5. Condition of System,
6. System Pumped By:
Neil.Bates7on F5821
Name Vehicle License Number
_Bat son Enterprises Inc
Company
7. LocaQQ-n where contents were disposed:
Lowell Waste Water
Sign miul Date
MnM.doo-08/03 System Pumping Record a Page 1 of 1