HomeMy WebLinkAboutSeptic Pumping Slip - 73 RIVERVIEW STREET 12/6/2016 Coma onwoaith of Massachusetts
Ci, Y/TQwn o NORTH ANDOVER MASSACHUSETTS
.. , ., �
Y stern Pumping
Record
Form 4
DEP has provided this form for use b local System � .f,�(��b
l Boards of Y Health. he System Pumping Rec rd mu!
be submitted to the local Board of Health or other approving a th
A. Facility Information
Important;
When ruing out 1. System Location: 21 � ��
farms to the � � ,
computer. use �, c.-.� ,�"1 ��',� ' �
only the tab key Address ( _ ..____._, _,.._..__ . ..:._�.. .
to move your /X .d � ° k�
cursor•do not _.. ,. __.� .',
use the return City/Town _ _ State
Key.
2. System Owner; Zip Cods
. w
Address —.___,_.._...
(If different from Location) --
Cltyf.r wn State Zip CodS
Telephone Number - --•_,._._..
, Pumping Record --�—
��� c
11 Date of pumping -
Date 2, quantity Pumped:
-, Gallons
Type of system; ❑ Cesspool(s) �ptic Tank ❑ Tight Tank
❑ Other describe
4. Effluent Tee Filter present? ❑ Yes ( No If y , as it cleaned? ❑ Yes
es w ❑ No
5. Condition of System;
»�...„,..,_ _.{-. ...4.... Ire.. .....___.
6, Sy em Pumped By;
ame Vehicle License Number
Company
7. Location where Contents were disposed:
SI ature of Hau =.._._____.._.__
4
Date
http://www,masg,gov/dep/water/ proya1s/t5forms,htm#inspect
4
t5farm4.docl 06103
System Pumping Record -Page i of ?
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TOWN OF NORTH ANDOVER
u Ole-, HEALTH DEPARTMENT
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