HomeMy WebLinkAboutSeptic Pumping Slip - 30 TANGLEWOOD LANE 9/11/2017 Commonwealth of Massachusetts
City/Town of NORTH ANDOVER, MASSACHUSETTS
System Pumping Record
Form 4
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. '"
When filling out 1. System Location:
forms on the
computer,use _ cr _...,,.f n.��>{F_iu�� CZ
only the tab key Address
to rnove your
cursor-do not – ....1.`4.R..l. ..x_ .... - -- _ _.— _._. ...-._– —.
use the return Cityf(Town State Lip Code
key. 2. System Owner:
Name – --
r
Address(if different from location)
Cityffown State Zip Code
Telephone Nurnber
B. Pumping Record
1. tate of Pumping �...� .-- 2. Quantity Pumped:
Date C.'>allons
3. Type of system: [ Cesspool(s) L,1--Septic Tank F1 Tight Tank
❑ Other(describe): --
4. Effluent Tee Filter present? ❑ Yes ['�No If yes,was it cleaned? [_] Yes ❑ No
5. Condition of System:
f 7
t.._10 C) C4,
6. System Pumped By:
Name Vehicle License Numt7er
Company
7. Location where contents were disposed:
`ri�tjref Hauler bate_ —
ttttp://www.mass.gov/dep/water/approvals t forms.htm#inspect
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