HomeMy WebLinkAboutSeptic Pumping Slip - 56 CANDLESTICK ROAD 5/20/2016 Commonwealth of Massachusetts
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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. l
A. Facility Information t
Important:
When filling out 1. System Location: ] �
forms the -
computer, use � /.� C
only the tab key Address F0ALTH DE-PAMVENT
to move your mr ° __._
cursor-do not Cityfrown State Zip Code
use the return
key. 2. System Owner:
ream Address(if different from location) -
Cityfrown -- State —----.--- Zip Code
Telephone Number _
B. Pumping Record
1. Date of Pumping 4 --- 2. Quantity Pumped: calf
Date ons
3. Type of system: ❑ Cesspool(s) m'/Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yest,0 No If yes, was it cleaned? ❑ Yes ❑ No
i
5. Condition of System:
& System Pumped By:
Name Vehicle License Number
Company
7. location where contents were disposed:
Signature of Hauler Date
http://www"mass,gov/dep/water/approvals/t5forms"htm#inspect
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