HomeMy WebLinkAboutSeptic Pumping Slip - 318 SALEM STREET 9/11/2017 Commonwealth of Massachusetts
(} r� City/Town of DPNH ANDOVER
, MASSACHUSETTS3
System Pumping Record
Form 4
CBPP has provided this forrin for use by local Boards of Health. The System Purr?400Ord r
be submitted to the local Board of Health or other approving authority. I 1"
A Facility Information _ (ft
Important:
When filling out 1. System Location-.
forms on the a C 1
Computer,use
only the lab key Address
to move your
cursor-do riot
use the return City/Town Sate "Lip Code
key. 2. Systermi Owner: (p , ,O
c;'../{ }iC� ' C',.F- I s
Name
h1_1
A=i Address(f different from location)
_._
City/Town State Zip Code
Telephone Number
B. Pumping record
1. Date of Pumping _,_.__...._ 2. Quantity PLimped:
Date Gallons
3. type of system: ❑ Cesspool(s) [optic-tank ❑ Tight Tank
U Other(describe): _. _._...
4. Effluent Tee Filter present? ❑ Yes ❑ o If yes,was it cleaned? ( Yes [� No
5. Condition of System:
6. System Pumped By:
7—,C
Name Vehicle License Number
Company -
7. Location where contents were disposed:
a
4ignaliure of Hauler Date
http://www.mass.gov/dep/water/approvals forms.hlmf€inspect
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