HomeMy WebLinkAboutSeptic Pumping Slip - 66 HAY MEADOW ROAD 10/24/2007 Commonwealth of Massachusetts
City/Town of NORTH ANDOVER MASSA
�fl
h y'
m System Pumping Record
Farm 4
the local Board of Health or other a rove "'` r.l g Record must
DEP has provided this form for use b local Boards of He Ith T'he t
be submitted to pp
A. Facility Information
Important:
When filling out 1. System Location.
forms the
computer,use
only the tab key Address
to move your �� . "
cursor-do not City/Town State Zip Code
use the return
key. 2. Sy t ,em Owner: p
�441 0`0 V 41,60
Name
+g, Address(if different from location)
City/Town Stae Zip Code
Telephone Number
B. Pumping Record I Soo
1. Date of Pumping A!, � 2. Quantity Pumped: eauo-- 'n5
I Type of system: ❑ Cesspool(s) CO"'Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes E#/No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
1 Ott
6. Svstem Pumped By:
Nt e Vehicle License Number
Company
7. Location where contents were disposed:
(ii L C�N
(R=� 6,)� - - -
Signature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
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