HomeMy WebLinkAboutSeptic Pumping Slip - 193 BERRY STREET 9/11/2017 Commonwealth of Massachusetts
I tE" �} City/Town of NORTH ANDOVER, MASSACHUSETTS
System Pumping Record
t J � Form 4
DEP has provided this form for use by local Boards of Health. The System Pumping must
be submitted to the local Board of Health or other approving.' authority. �
A. Facility Information CIO,_
Important: C7 Q
When filling out 1, System Location: �yCre
forms on the
computer,useA % -
✓ , c
only the tab key Address
to move your
cursor-do not -._...._._. _ ..._ __..._ _ ......_. —_._—,..._ _.
use the return Cityfrown State Zip Code
key.
2, System/Owner
rad 0}L le..,
- �
Name; __..
Address(if different from location) -
Cityrrown State Zip Code
Telephone Number
BA Pumping Record
1. Date of Pumping [gate.._..�._._..- --_ 2. Quantity Pumped;
Gallons
3, Type of system: [] Cesspool(s) _. Septic Tank Tight Tank
❑ Other(describe): _---
4. Effluent Tee Filter present? Yes Fvj No If yes,was it cleaned? Yes �.� No
5. Condition of System:
6. System Pumped By:
c7—/
Name Vehicle License Number
Company
7. Location where contents were disposed:
Siena ure of Hauler Date
http://www.mass.gov/dep/water/approvals forms.htm##inspect
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