HomeMy WebLinkAbout- Septic Pumping Slip - 1080 TURNPIKE STREET 10/31/2018 Commonwealth of Massachusetts RECEWED
City/Town of
12 01
System Pumpling Record
Form 4 �EAL'h�DEFIARTMENT
rOWN 01:NOF-'T i,l ANDOVER
DEP has provided this form for use-by local Boards of Health. Other forms maybe*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 forrh they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility InforMation
1. System Location Ightfron_,-o--
f hhoguse), Left/Right rear of house, Left/right side of house, Left
Right side of boil Location'
ALeft Right front of building, Left/Right rear of building, Under deck
Address
U ..............
ZW7—rown State Zip Code
2. System Owner
Name'
Address(if different from location)
cityfrown
zi
Telephone Number
® Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system: El Cesspool(s) 0-t�eptla Tank El Tight Tank
Other(describe):
4. Effluent Tee Filter present.? [j Yes El"Co If yes, was it cleaned? Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Bates7on F5821
Name Vehicle License Number
Bateso iEhte!prises Ina
Company
7, Lo flonp0h7re contents-were disposed:
Lo "on
Lowell Waste Water
Hauls
Sign e Haul Date GC
06=4.doo-06/03 System Pumping Record m Page 1 of 1