HomeMy WebLinkAboutSeptic Pumping Slip - 175 FOREST STREET 9/11/2017 Commonwealth of Massachusetts
City/Town of NORTH ANDOVER, MASSACHUSETTS
T
System Pumping Record
DEP has Provided this form for use by local Boards of Health. The System Pumping Retst
be submitted to the local Board of Health or other approving authority.
A. Facility Information
Important:
When filfing out 1. System Location:
t ''
forms on the
computer,Use `'F
only the tab key Address
to move your
cursor-do not —"own -
S.._...__.
use the return Crit yrT Mate lip Cade ...—
key.
2. System owner:
flame
Address(if different from location) '..
Cityrt own ;sate Zip Code
Telephone Number
B. Pumping Record
1. Date of Bumping tante >Y�rf 2. Quantity Pumped:
Lallans
1 Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
Other(describe): ....... _.._
4. Effluent Tee Filter present? [,� Yes <o Ify-es, was it cleaned?
[] Yes L,] No
5. Condition of System:
6. System Pumped By:
r 7
Name Vehicle L.rcense Number
Company
7. Location where contents were disposed:
rgn<r rrrc of Hauler hate
http://www.mass.gov/dep/water/approvals forms,htm#inspect
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