HomeMy WebLinkAbout- Septic Pumping Slip - 962 TURNPIKE STREET 11/26/2018 F2ZECEVED
Commonwealth of Massachusetts
City/Town of NOV ? (3 ?018
i ANDOVER
System Pumping Record TOWN OF NU' I G
Form 4 T�,.�DEPARTMEN'r
DEP has provided this form for use-by local Boards of flealth. Other forms may,be'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 forrh they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Fact'llity InforMation
1. System Location: Left/Right front of house, Left/ _ Left/right side of house, Left./
Right side of building, Left/Right front of building, Left I%fitriar of building, Under deck
Address 6"' 1\
t7�
Cityfrown state Zip Code
2. System Owner.
Name'
Address(W different from location)
cityrrown Zip Code
Telephone Number
® Pumping ftecord
1. Date of Pumping Date 2. Qua My Pumped: Gallons
3, Type-of systern: E] Cesspool(s) 3-Se-p—ri-c Tank Tight Tank
E3 Other(describe):
4. Effluent Tee Filter present? E] Yes 3_14o� if yes, was it cleaned? Yes E] No
6. Condition of System,
6, System Pumped By:
Nell.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo"lfcop. h-ere"""qontents-were disposed:
SigoG, a. Lowell Waste Water
ne Hibiul Date
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