HomeMy WebLinkAboutSeptic Pumping Slip - 315 SOUTH BRADFORD STREET 1/1/2006 Commonwealth of Massachusetts
- r City/Town Of NORTH ANDOVER, MASSACHUSETTS
System u in Record
Form 4
DEP has provided this form for use by local Boards of meal h, Tb $ysW Pumpir!g Record must
be submitted to the local Board of Health or other approvin autfi �,r
A. Facility Information 8
Important:
When filling out 1. System Location: -1 U'/VH 01':
forms on computer, use r / �� T f [} > E t
n- _W
p '�"� " ?:/�F't.�>'� ` ". ..�m. a m.... m,
C.
only the tab key Address
to move your ),-,.
cursor-do not —
use the return City/Town State Zip Cade
key. 2. System Owner:
Name
return '`� — - ----------
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping ` ° 2, Quantity Pumped:
Date Gallons
3. Type of system: Cesspool(s) ❑ Septic Tank ❑ Tight Tank
❑ Other(describe): — -- —
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. Syr� B
Pumped_.,y
:
_ — -----
Name Vehicle License Number
Company
7. Locat ere contents were disposed:
i
Sign/�tdr f aut r Date
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