HomeMy WebLinkAboutSeptic Pumping Slip - 60 INGALLS STREET 8/15/2017Important:
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Commonwealth of Massachusetts
City/Town of
System Pumping Record NORTH ANDOVER
Form 4
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101'41\k CI140FkINODOVER
NEPLIN DEPINAItg.11I
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 within 14 days from the pumping date In
accordance with 310 CMR 15.351.
A. Facility information
1. Syst m Locatioa: ..ece7
, I
Are
bity/Town
2. Syst Owner:
Name
Address (If different from location)
B. Pumping R
1. Date of Pumping
3. Type of system; 0 Gesspool(s)
1:1 Other (describe):
4, Effluent Tee Filter present? 1:1 Yes
5. Condition orm:
Company
7. Location wh41418t
ord
Signature of Receiving Facility
Cate
Stale
2, Quantity Pumped:
cte7.,S
ziiiCccrae"
eptic Tank 0 Tight Tank 0 ,Grease Trap
If yes, was it cleaned? 0 Yes ED NO
Cate
'cie License Number
t5rOrrn4.cloc• 03/06 System Pumping Record - Page 1 of 1