HomeMy WebLinkAboutSeptic Pumping Slip - 143 MILL ROAD 9/11/2017 Commonwealth of Massachusetts
City/Town of NORTH ANDOVER, MASSACHUSETTS
Y stere Pumping Record
}7 Form 4
AVID
IEP has provided this form for use by local Boards of Health. The System Og Re(;acrd 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 G~�
computer,use !... .__ }'�
only the tab key Address
to move your �
cursor-do not — .. .._�` ,_L t..r: _ —. _._. -
use the return Citylf'own State Zip Code
key.
2. System Owner:
VQ
6C ....__� .- 1 .-,.._.
Name
k° Address(if different from location)
__-.... .._ ...__ m..._
GitylTown State Zip Code
..,.._.
Telephone Number
B. Pumping Record
1. Date of Pumping [gate ?. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) [;rSeptic Tank ❑ Tight Tank
❑ Other(describe): ___ __ -_...__
4. Effluent Tee Filter present? ❑ Yes F4/No If yes, was it cleaned? [I Yes ❑ No
5. Condition of System:
GI-0«
6, System Pumped By:
Name Vehicle License Number
Company
i
7. Location where contents were disposed.-
z
i
Signafure of Hauler _ Dath
http://www.rnass_gov/dep/water/approvals?t--form's.11 inspect
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