HomeMy WebLinkAboutSeptic Pumping Slip - 54 OLD CART WAY 3/10/2008 Commonwealth of Massachusetts �.� � ..RECEIVE
City/Town of
Form 4
TM(N OF NCR� ANDOVER
11EA1"i f-f Y:EP-"AW"Mr,:,Rl
DEP has provided this form for use by local Boards of Health. Other krnffi s icy Yvsed;°butmthW
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
Important:
When filling out 1. System L Catlon:
,
forms on the
computer, use
only the tab key Address . y F w••
to move your ° G� "
M
cursor-do not City/Town Stat Zip Code
use the return
key. 2. System Owner:
Name - -
n Address(if different from location) -
City/Town State Zi Code
Telephone Number
B. Pumping Record ,,
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ❑w-9eptc Tank E❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of S ystem: �
li4e,
7 ..._.
6. Sys empum By-
Name
pM
Vehicle License Number
`3c
Company
7. Locatio here conts If
)disposed:
...
Signatu of a Date t
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