HomeMy WebLinkAboutSeptic Pumping Slip - 70 OAKES DRIVE 4/28/2009 Commonwealth of Massachusetts
City/Town of NORTH ANDOVE
R"MASSACHUSETTS
System Pumping Record
Form 4
DEP has provided this form for use by local Boards ofj_tCth,j_hLqy
be submitted to the local Board of Health or other app ovin ing Record must
PIT"VIVED
A. Facility Information MAY 0 6 2009
Important:
When filling out 1. System Location: 'OWN OF NOR I H ANDOVER
forrns on the '7C) CXt:,, HEALTH DEPARTMEN'r
computer, 'use
only the tab key Address
to move your
cursor-do not
use the return City/Town Stak Zip Code
key. 2. System Owner,
rod R -7e
Name
Address(if different from Iodation)
CityfTown State —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):
00/1
4. Effluent Tee Filter present? es El No If yes, was it cleaned? Yes ❑ No
5. Condition of System:.
6. m
Syst Pumped By:
-
2
Nam Vehicle License Number
Company
7. Location where contents were disposed:
UIN
1A�
L
Signature of Hauler I
Date
http,//www.mass.gov/dep/water/approvaIs/t5forms,htm#inspect
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