HomeMy WebLinkAboutSeptic Pumping Slip - 1500 SALEM STREET 9/11/2017 Commonwealth of Massachusetts
s r n City/Town of NORTH ANDOVER,
�) System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. The System Pumping Recor
be submitted to the local Board of Health or other approving authority.
A. Facility Information
Important:
when filling out 1 System Location: 0 top,
forms on the
t CT la c f c yw'
computer,use ......_._ �..__ t r:� 7
only the tab key Address
to move your
cursor-do not _. _..._. __._.
Cit frown —
use the return y state Zip Code
key.
2. System Owner-
Name
nsn if
Address different from
- ------� ( location)
Cit Crown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping -- " _. _.....__. 2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) ` Septic Tank ❑ Tight Tank
❑ Other(describe): — --
4. Effluent Tee Filter present? FYes ❑ No If yes,was it cleaned? Vf Yes ❑ No
5. Condition of System:,
'Ll-za
6. System Pumped By:
Name Vehcicle t ieense Number
_. _......_ _.._.._....__.__--
Company _.._..__-....__
7. Location where contents were disposed:
Signa ure of Hauler � Date
_.
http://www.mass.gov/dep/water/approvals/t forms.htm##inspect
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