HomeMy WebLinkAboutSeptic Pumping Slip - 357 CANDLESTICK ROAD 6/22/2017 Commonwealth Of Massachusetts RECEIVED
City/Town of
JUL 0 5 201 i
I System Pumping Record yOWN OF NORTH ANDOVER
Form 4 WALTH DEpARTMENT
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record 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
only the tab key Address
to move your ---
cursor-do notA L/,^"6'
use the return Tlt�yffown 4!26
key. 2. System Owner: State Zip—C—o Cade
/—,(' V\ Ca V\ 0
Address(it different from location)
CILYt town
Skate
YIP Cod—e ---
"7
Telephone` —--Number
B. Pumping Record
1, Date of Pumping -6ate 4--")Q (-7 2. Quantity Pumped:
Gallons
3. Type of system: 0 Cesspool(s) ,1K.Septic Tank F1 Tight Tank
M Other(describe):
4. Effluent Tee Filter present? 0 Yes �l\lo If yes, was It cleaned? ❑ yes ❑ Na
5. Condition of System:
6. System Pumped By:
Name
2-C k� o41 t Vehicle License Number
Company
7. Location where contents were disposed:
Z--�-D
Signature of Hauler
Date
t5form4.doc,06/03
System Pumping Record•Page 1 of 1