HomeMy WebLinkAboutSeptic Pumping Slip - 183 FOREST STREET 9/11/2017 Commonwealth of Massachusetts
City/Town of NORTH ANDOVER MASSACHUSETTS
System Pumping Record
Forret 4
DEP 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.
A. Facility Information
Important:
When
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2. System Owner:
4Q—
Name
ymsrn _ Address if different from location)
City/Town State Zip Code
Telephony Number
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B. Pumping Record
1. Date of Pumping tate : / - 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) ( eptic,Tank ❑ Tight Tank
F Other(describe):
4, Effluent Tee Filter present? __ Yes ❑ No If yes, was it cleaned? c Yes [) No
5. Condition of System:
6. System Pumped By:
Name Vehicle t icense Number
Company....
7. Location where contents were disposed:
I
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Siynati.irc of I tauter Gate
http://www,rriass.gov/dep/water/approvalst
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