HomeMy WebLinkAboutSeptic Pumping Slip - 1044 JOHNSON STREET 9/11/2017 Commonwealth of Massachusetts
City/Town of NORTH ANDOVER, MASSACHUSETTS
System Pumping Record
, > Fora 4
IEP has provided this form for use by local Boards of Health. The System Pumping Rcord must
be submitted to the local Board of Health or other approving authority.
_...._ __.___... _ —-------
A. Facility Information h�'1%
Important: �:;, f y�ao*R
Wben filling
eout 1. System Location:
forms on t fief c7,C! �•
computer,use
only the tab key Address _
to move your f YM
cursor-do not .. _..._...._ -
use the return t,ityl-rown State Zip Code
key. 2. System Owner: t
rb
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
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1. Date of Pumping -- 2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) ER Septic Tank ❑ Tight Tank
❑ Other(describe): -
4. Effluent Tee Filter present? ❑ Yes _ No If yes, was it cleaned? ❑ Yes E-j No
5. Condition of System::
t c t.-' It
6. System Pumped By:
Name
Vehicle License Number
Company
7. Location where contents were disposed:
Signa ure,of Hauler pate _.,.
http://www.mass.gov/dep/water/approvals forms.htrrt#inspect
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