HomeMy WebLinkAboutSeptic Pumping Slip - 614 SHARPNERS POND ROAD 9/11/2017 Commonwealth of Massachusetts
ai City/Town of NORTH ANDOVER, MASSACHUSETTS
v System Pumping Record
Fora 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: +t4l"*5
When filling out 1. System Location: d
forms on the ( C)
computer,use __. / v�)'-1'rC r..lZ A f {
only the tab key Addressto move Your
cursor-do not __........ .__.- -
use the return Cityrfown State Zip code —
key.
2. r.�ystern owner
- Narne
Address(if different from location)
City/Town State Zip code
Telephone Number
B. Pumping Record
��.�..._�,�
1. tate of Pumping - 2.. Quantity Pumped,-
Date
Gallon,
I Type of system: ❑ Cesspool(s) . Septic Tank U Tight Tank
L] other(describe): --
4. Effluent-fee Filter present? �es ❑ No If yes, was it cleaned? Fell"`(es ❑ No
5. Condition of System:
6. System Pumped By: 1
Name vehicle License Number
Company
7. Location where contents were disposed:
{
>ignafore of Hauler Date
http://www.rnass.gov/dep/water/approvalst'forms.htm#inspect
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