HomeMy WebLinkAboutSeptic Pumping Slip - 56 CANDLESTICK ROAD 8/21/2017 -ell, Commonwealth of Massachusetts
City/Town of NORTH ANDOVER MASSACHUSETTS
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. The Systern Pumping Record must 1
be submitted to the local Board of Health or other approving authority. 1
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A. Facility Information
Important:
When filling out 1- System Location.
forms on the /
computer, use
only the tab key Address
o move your 's / _.L! 1� _ 5
cursor-do not ��J
use the return City/Town St Code
key. 2. System Owner: A
coe
NameA�,
nen _ Address(if different tram location)
-
City/Town State Zip Code
Telephone Number
B. bumping Record
1. Date of Pumping ' ( � 2. Quantity Pumped: p (�
Date al"lois
3 Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
[❑ Other (describe):
4 Effluent Tee Filter present? ❑ Yes Vo If yes, was it cleaned? ❑ Yes 0 No
I
5. Condition of System:
0 / _
_ _ t
System Pumped By:
Name_ Vehicle License Number
'r
Company
7 Location where contents werK"s
__I _
Signature f ler Date
http://www.mass.gov/dep/w r/approvals/t5forms.htm#inspect
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