HomeMy WebLinkAboutSeptic Pumping Slip - 53 SPRING HILL ROAD 9/11/2017 Commonwealth of Massachusetts
City/Town of NORTH ANDOVERMASSACHUSETTS
_ System Pumping Record
Form 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: k
When filling out 1. System Location:
forms on the
computer,use a:. ' _..... �2 orty..`S_�.t r ✓.._ % "` '
- _...
only the tab key Address _
to move your
cursor-do not - `-...- __......_
Cit (fawn ---_.,..--
use the return y State ....__ Zip Cade
key.
2. System Owner-
IV
Name -.. —_...
WK
_ _......
Address(if different from lacatian}
—__..
cityffown State Zip Cade
etephane Number
B. Pumping record
1. Date of Pumping f �.-
P g Dat _ / 2. Quantify Pumped:
Lallans
3. Type of system: El Cesspool(s) [-]--S'eptic Tank Tight Tank
❑ Other(describe): ...... _ ...—_.... —__..__
4. Effluent Tee Filter present? [r�Yes ❑ No If yes, was it cleaned? Yes [� Na
5. Condition of System/:`
6. System Pumped By:
< ....
Name Vehicle License Number
Company —...
7. Location where contents were disposed:
Signe of Hauler D��ke�a.. _._�—_
http://www.mass.gov/dep/water/approvals forms.htm#inspect
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