HomeMy WebLinkAboutSeptic Pumping Slip - 137 HAY MEADOW ROAD 3/31/2016 Commonwealth of Massachusetts
City/Town of NORTH ANDOVER MASSACHUSETTS
System Pumping Record
Form 4 ,
DEP has provided this form for use by local Boards of Health. The System Pumping Record must
be submitted to the local Board of Health or other approving authority.
A. Facility Information
Important:
whenth out 1. System Location: I � Hinn forms on the y— X on computer,use X
only the tab key Address
your
to move not —n °
use the return City/Town State Zip Code
key. . 2. System owner.
V
Name
Address(If different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record /
1. Date of Pumping D/�� 2, Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) ,YSeptic Tank ❑lTight Tank
Other(describe): —j `-�
x
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
0 /0.t 1h e fi/no-4
6. System Pumped By:
Ce
��
a!LL Vehicle License Number
LC'r.(� � r I�
Company
7. Location Abpre contents were disposed:
bo i I/ LT, 8 r
Signature of Hauler Date
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pp g authority,
A. Fqc111tyJnforrM
ption -
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Date-of Pumping ` Date 2. Quantlty Pumped; --
Gans
Typ4 pf s stamr
Y Cesspool(s) eptic Tank ® Tight Tank,
I Ether(de�scribe)�� �v �' —
1"(Ht�
Effluent Tee Filter present?,❑ Yes,two If yes, was It cleaned?
® s
I Ye ❑ No
,
I/Condition of Syst�mi,'� r
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6 Sy q Pumped sy�''
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,, { 7, Location where oantents Wpr�dipased;
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t� '•t l' �! '!{1' J //.4k( rm ' Vtna, ®® aV�C;itit/`.�,.+�ryl;l� r, I.. Date
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System Pumping Record