HomeMy WebLinkAboutSeptic Pumping Slip - 1929 SALEM STREET 9/11/2017 � x Commonwealth of Massachusetts
(f� City/Town of NORTH ANDOVER i�➢ , USE'rT
6
System stePumping Record
,f Form 4
DEP has provided this form for use by local Boards of health, The System Pumping Rec must
be submitted to the local Board of Health or other approving authority.
A. Facility Information
Important:
When filling out 1. System Location: q
firms on the r `
computer,use ...._— '' /e.!fj � .._... �C1Q�t.
_— _ ___
only the tab key Address
to move your ( f 14
cursor-do not _ _ _ — ..._... .
use the return City[Town State Zip Code
key. 2. System Owner:
Name
__ ._..._...... _....._.._ _....., ._.,..._-
0XI Address(if different from location)
Cityfrown State Zip Code
- ----— _
Telephone Number
B. Pumping Record
1. Date of Pumping C —� 2. Quantity Pumped,-
Date / _,..._ ......
Gallons
3. Type of system: ❑ Cesspool(s) L" Septic Tank ❑ Tight Tank
F1 Other(describe):
4. Effluent Tee Filter present? . Yes ❑ No If yes, was it cleaned? ❑Yes ❑ No
5. Condition of System:
crt�Cj.
6. Syst�e!m Pumped By:
Name Vehicle License Numher
Company
7. location where contents were disposed;
e
SignaOire of Hauler Gate
1
http-//www.niass.gov/dep/water/approvals/dforr'ns.htr-n#inspect
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