HomeMy WebLinkAboutSeptic Pumping Slip - 114 SPRING HILL ROAD 9/11/2017 Commonwealth of Massachusetts
City/Town of NORTH ANDOVER, MASSACHUSETTS
System Pumping Record
Fora 4
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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 y _
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When fillip out � stem Location:
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2. System Owner:
Name _.._...._._ __....
Address(if different from location)
Cityfrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumpingat ..rte s — 2, Quantity Pumped: d >"`��,
Gallons
3, Type of system: ❑ Cesspool(s) 0--septic Tank ❑ Tight Tank
Other(describe): -_.. . . __. .._.,..... ..
4. Effluent Tee Filter present? Yes [ J Na If yes,was it cleaned? I+° Yes L1 Na
5. Condition of System:
6. System Pumped By:
� , 7-/C—
Dame Vehicle License Number ___,....._.
i
Company t
7. Location where contents were disposed:
Srgna ure of Hauler Date
http://www,mass.gov/dep/water/approvals forms.htm#inspect
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