HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 20 NORTH CROSS ROAD 5/26/2020 Commonwealth of Massachusetts RECEIVED
MAY 2 6 2020
= City/Town of
System Pum in Record TOWN LT ANDOVER
p g HEALTH DEPARTMENT
Form 4
DEP has provided this form for use=by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using Ahis form,check with your
local Board of Health to determine the form 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: Left/Right front of house, Left/Right rear of house4_4/right side of house, Left
Right side of building, Left/ Right front of building, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2, System Owner.
Name'
Address(if different from location)
Cityfrown Stat Zip Code
Telephone Number
B. Pumping Record _
9. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) 0—eeptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System_:
i
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. ' ere contents-were disposed:
7L SJP Lowell Waste Water
Sign WeHaul Date
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