HomeMy WebLinkAboutSeptic Pumping Slip - 174 GRAY STREET 9/11/2009 Commonwealth of Massachusetts
.
pity/Town of NORTH ANDOVER, M
ASSA
- System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Wealth. The1Sy*m PumpIng'R0c'grd,must
be submitted to the local Board of Health or other approving authority,
A. Facility Information
Important:
When filling out 1. System Location:
forms on the
computer, use. w,
only the tab key Address -
to move your
cursor-do not iAvvto
use the return City/Town State Zip Code
key.
2. System Owner:
Name — ——
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
C�i1. Date of Pumping
p g Date uantity Pumped: Gallons
3. Type of system: El Cesspool(s) 2.eptic Tank ❑ Tight Tank
tt
❑ Other(describe): _-
4. Effluent Tee Filter present? ' Yes ❑ No If yes, was it cleaned? Yes ❑ No
5. Condition of System:.
r
�
6 System Pumped By:
Name
Vehicle License 4%n�'
Company --
7. tents were disposed: n
Location where can � ..
Signature of Hauler Date
http,//www.mass,gov/dep/water/approvaIs/t5forms,htm#inspect
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