HomeMy WebLinkAboutSeptic Pumping Slip - 142 BOSTON STREET 9/11/2017 Commonwealth of Massachusetts
I City/Town of NORTH ANDOVER, MASSACHUSETTS
System Pumping record
t Form 4
DBP has provided this form for use by local Boards of Health. The System Pumping R st
be submitted to the local Board of Health or other approving authority.
A. Facility Information
Important: v
When filling out 1. System Location: i
forms on the Jf
computer,use .�le ,-)e16A' _......._._...._....— _..--._, . .. .._.only the tab key Address
to move your n
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. Date of Pumping _.__.._....._.._._ ____ 2. Quantity Pumped:
Date Gallons
3. Type of system: [ Cesspool(s) N Septic Tank ❑ Tight Tank
Other(describe); _..... _
4. Effluent Tee Filter resent? ? _...
p [ ] YesZ;- No If yes, was It cleaned? [_] Yes [ ] No
5. Condition of System:
(71 4
6. System Pumped By:
7
Name Vehicle License Number
Company
7. Location where contents were disposed:
Signa ure of Ft ul ..fir Dat --- .._...`_..�....f ..._ _
e
http://www.mass.gov/dep/water/approvals forms.litm#inspect
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