HomeMy WebLinkAboutSeptic Pumping Slip - 770 BOXFORD STREET 9/11/2017 ` = Commonwealth of Massachusetts
m.
City/Town of NORTH ANDOVER, MASSACHUSETTS
stere Pumping Record
Form 4
DBP 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: C `
forms on the �1 ��
computer,use — j r7!3 _ d �iiz. r 7 .. ,, C y"
only the tab key Address _-- 0,
only to move your f�
cursor-do not ..._
use the return City/Town State Zip Code
key. 2. System (.owner:
Name
_ Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. gate of Pumping _.... _. / �" _`.._° ..- 2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight.Tank
] Other(describe):
4. Effluent Tee Filter present? ❑ Yes �o If yes, was it cleaned? ❑ Yes ❑ No
5, Condition of System:
6, System Pumped By:
Narne Vehicle License Number
Cornpany
%. Location where contents were disposed.-
of
isposed:of Hauler Date
littp://www.mass.gov/dep/water/approvalsforms.htrn#inspect
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