HomeMy WebLinkAboutSeptic Pumping Slip - 501 BOXFORD STREET 9/11/2017 Commonwealth of Massachusetts
P, City/Town of NORTH ANDOVERMASSACHUSETTS
System Pumping Record
Fora 4
PEEP has provided this farm 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: (u �
forms on the „
computer,use _... ...t>/ 62z1/— F
only the tab key Address
to rrrove your
cursor-do not _...._.._ �._ .. ...._.....- --_.. .
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use the return cit Yrrowrr State Zip Code
key. 2.
System Owner
__ / -----------,__. __. --
Address(if different from location)
Cityfrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping -- - 2. Quantity Pumped: -
Date (.3allons
1 Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? t� Yes ❑ No If yes, was it cleaned? ( Yes ❑ No
5. Condition of System:
6. System Pumped By:
7 C—
Name Vehicle License Number
Company
7. Location where contents were disposed:
Signa ure of Hauler Date
http://www.mass.gov/dep/water/approvals aforms.htm#inspect
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