HomeMy WebLinkAboutSeptic Pumping Slip - 1475 OSGOOD STREET 9/11/2017 Commonwealth of Massachusetts
{b City/Town of NORTH ANDOVER, MASSACHUSETTS
P —
'_J0 Systems Pumping Record
Form 4
DBP has provided this form for use by local Boards of Health. The System Pumpingd must
be submitted to the local Board of Health or other approving authority. "
Oft
A. Facility Information
Important: ,.� .., � e5
When filling out 1. System Location: r "o?" �
forms on the
computer,use � 5�! 1
only the tab key Address
to move your
cursor-do not
Cit /Town --
use the return y State Zip Code
key.
2. System Owner:r
Name I
'-d`'�"" "-�-� Address(if different from location)
i
Cityrrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping - > 2. Quantity Pumped:
,.—
Date Gallons
3. Type of system: ❑ Cesspool(s) LI/Septic Tank ( Tight Tank
Other(describe): _.........
_
4. Effluent Tee Filter present? [Zr'�es ❑ No If yes,was it cleaned? [_,r Yes ❑ No
5. Condition of System:
6. System Pumped By:
p7
Name
Vehicle license Number
—
------
_.....
Company _.
7. Location where contents were disposed:
Signature of Hauler Date
http://www.mass.gov/dep/water/approvalsforms.htm#inspect
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