HomeMy WebLinkAbout- Septic Pumping Slip - 313 SUMMER STREET 7/2/2019 Commonwealth
r"Vat'.1E,
Er"
I f r::
M Cpt�/Town
.�
J
olf
•
� tein
r
"I' ANDOVER
YS
w
r'l n AL ,YA
Fonn 4
DEP he's
provided this formw for use;;by,local, r w -,Health. Other formis may,beused,but,the
information-must be substantiallythat provided here. Beforesg. i form, ,check with your r
foc,6113,oard of Health to determine, y use. The$ystem Pumpin r must be submittedc
focal Board of Healthor other approving
w
A. y
Facill"',,itl w
Systemw � X front r
i
I
Righti building, E r- iliw L rear
Add m
Cidy/Tbwn State Zl'p Code
2. System Owner: � w
w
Addressdifferent from location)
wStatn p
w
Telephone Number
a�
w w
k
,ter t
I
Pgm-ping
PumpingI Date of .. w
M
Date Gallons
cnk 3
Tight Tank. 'Type-of sy�terft: El Cesspool(s) 9___ge�pfi Ta
Other(describe):
4., Effluent Tee Filter present? Yes 0011CO If yes, w,as it cleaned? Yes No
* i iton of System:
..
w a
x
ON,
;, $ystem Pump y
Nell. s Jon F5821
�N rn _ Vl License Number
Bates Bateson Ehterprises Inc-
Company
7. Location. R ,ere content&were disposed.,
Sign 0 Hbul Date
.1 Pumping r
M