HomeMy WebLinkAboutSeptic Pumping Slip - 550 JOHNSON STREET 9/11/2017Important:
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Commonwealth of Massachusetts
r, 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 Re
be submitted to the local Board of Health or other approving authority.
A. Facility Information
1, System Location:
Address
A.-
City/Town
2, System Owner:
Name
Address (if different from location)
City/Town
B. Pumping Record
o cktoolt
59,AE}a
Stale Zip Code
State
Telephone Number
Zip Code
'1 i s—e.ro
Date of Pumping 2. Quant ty Pumped:
Date Gallons
3. Type of system: El Cesspool(s) ,ErSeptic Tank 0 Tight Tank
LI Other (describe):
4, Effluent Tee Filter present? D Yes H1-\--lo If yes, was it cleaned? Ill Yes LI No
5. Condition of System:
6. System Pumped By:
/ 0 4
Name
Company
7. Location where contents were disposed:
72
Signaffire of Hauler
http://www.mass.govidep/water/approvals Uorms.htm#inspect
Vehicle License Number
- I 0- .7
Date
t5forn4,doc• 06/03 System Pumping Record • Page 1 of 1