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HomeMy WebLinkAboutSeptic Pumping Slip - 35 ROCKY BROOK ROAD 10/15/2015 1 . t Commonwealth of Massachusetts RECEIVED I City/Town of . System Pumping.Record ToVi OF NOW'H ANDOVER Form 4 HEALTH DFwPA MEN DEP has provided this form for use=by local Boards of Health. Other forms may be used, but the 1 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/Right front of house, Left/Right rear of house, Left/ ight side of houseLLeft/ Right side of building, Left/Right front of building, Left/Right rear of building, Under deck' Address Citylrown Skate Zip Code 2. System Owner. Name' Address(if different from location) Cityrrown ' State�° ' ; • ti Telephone Number r .B. Pumping JRacord „ ' „ 1. Date of Pumping 2. Quantity Pumped: Date Gallons 3. Type-of system: ❑ Cesspool(s) e l is Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ©°'No If yes, was it cleaned? ❑ Yes ❑ No, 5. Condition of.Syste?� ry ' '"Ax„.^'�-•.kF ....�'" r fw" '��"T'nl'^t• hd„ �:Arp.../j`w•.X w..,.. 6. System Pumped By: Neil.Bateson . F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Locatipp=whQre contents were disposed: ALSQ Lowell Waste Water SignAtute cf Haule Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1