HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 55 STONECLEAVE ROAD 12/7/2020 Commonwealth of Massachusetts
City/Town of � '
System Pumping Record 0 7 2020
Form 4 nF t JORIH ANDOVER
f ILE�T
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.this 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 Z2ight f nt of`se,.,Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address I -
- 0_�� 46,4\e Agt_��
City/rown state Zip Code
2. System Owner. _ ff
Name
Address(if different from location)
CiWrown State �1
_4
Telephone Telephone Number
B. Pumping record
1. Date of Pumping Date �2Qunfity Pumped: Gallons
3. Type of system, ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes D__14�0 If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
c7 � �-P� � CA
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatio here contents-were disposed:
�L S Lowell Waste Water
-�- �
SigWne Haul Date
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