HomeMy WebLinkAbout- Septic Pumping Slip - 130 CHRISTIAN WAY 10/31/2018 Commonwealth of Massachusetts (,C]" 312018
City/Town of
P)WN OF NOUH ANDOVER
System Pumping Record 1EAL i H DETIARTMENT
Form 4
DEP has provided this form for use=by local Boards of-Health. Other forms may'beused,but the
Information,must be substantially the tome 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 tc)
the local Board of Health or other approving authority.
A. Fact"fity Inn ormia'fit
on
1. System Location: Lefk��Righf"front of housq Left/Right rear of.house, Left/right side of house, Left I
I 'M #
. it- RiVht fron uildifig, Left/Right rear of building. Under deck
Right side of building, ftr AL
Address
h30 06,
City/Town States Zip Code
2. System Owner
Name'
Address(if different from location)
City/Town State —Zip Code
Telephone Number
Pumping K-ecord
1. Date of Pumping Date 2. Qu6ntity Pumped: Gallons
3. Type-of system: [] Cesspool(s) E3,-S'e'p_tic Tank Tight Tank
El Other(describe):
4. Effluent Tee Filter present.? El Yes If yes,was it cleaned? E3 Yes [3 No
5. Condition of System: � _C 0A
6. System Pumped By:
Nell.Batesbn F5821
Name Vehicle License Number
_Bateson Enterprises Inc
Company
7. Locatio vlaere contents-were disposed:
's
Lowell Waste Water
Sign a Haut Date
MbnM.doc-08/03 System Pumping Record®Page 1 of I