HomeMy WebLinkAboutSeptic Pumping Slip - 125 BOSTON STREET 9/11/2017 Commonwealth of Massachusetts
Citi/down of NORTH ANDOVER, SACHUSETTS
LSystem Pumping Record
Form 4
DEEP 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.
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A. Facility Information .._.._._
Important: 4"
When filling out 1. System Location:
forms on the yyt �GJrt r '1M by
computer,use " 4
only the tab key Address
to move your yy
cursor-do not
use the return City own State lip Code
key.
2. Systern Owner:
Name
Ad
.dr.....e..._ss._._, . ,
(if diff ....tian...-.) .,_..._.._—. ...._..._..... . _--_...-.._._....— ....._..-. ............. ._.....-., .....,.
erent from loca
Cityfrowrr State Zip Code
Telephone Number
B. PLIMping Record
r - - /( Wit.
1. Date of Pumping _._...._ 2. Quantity Pumped: _.__.. _... _ ....__.._
Date Gallons
3. Type of system: r_) Cesspool(s) [?r"Septic Tank ❑ Tight Tank
[ Other(describe):
4. Effluent Tee Filter present? F) Yes Ej""No If yes,was it cleaned? n Yes [� Na
5. Condition of System.-
6.
ystem:b. System Pumped By:
Name Vehicle license Number
C;orrrp
_...a__ny _..._.
7. Location where contents were disposed:
Sign ure of Hauler Date
http://www.mass.gov/dep/water/approvals/ �forms.htm#inspect
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t5forrn4.doc•06/03 Systern Purnping Record-Paye 1 of 1