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HomeMy WebLinkAboutSeptic Pumping Slip - 43 FULLER ROAD 9/11/2017 Commonwealth of Massachusetts q,� City/Town of NORTH ANDOVER, MAqSACHUSETTS 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. ------..._._..-...---- Alp A. Facility Information � Important: 9 �'V When filling out 1, System Location: o, forms on theme// } / computer,use .............__ �`c� only the tab key Address Na to move your cursor-do not ..........— _..___ — use the return Cityffown State Zip Code key. 2. System Owner: ens 'f2(L r /a'✓3✓U ... -.......... ---------_. _...... __..... --------- - -- - Name --s- ravorn Address(if different from location) City/Town State Zip Code Telephone Number --------- B. Pumping Record 1. Date of PumpingDate � 2. Quantity Pumped: gallons 3. Type of system: ❑ Cesspool(s) B--Septic Tank ❑ Tight Tank ❑ Other(describe): - 4. Effluent Tee Filter present? ❑ Yes E--No If yes,was it cleaned? ❑ Yes ❑ No 5. Condition of System: -------------- t,. c.. 6. System Pumped By: Name vehicle License Number Company 7. Location where contents were disposed: Signa ure of Hauler Date http://www.mass-gov/dep/water/approvals forms.htm#inspect t5form4.doc•06/03 System Pumping Record•Page 1 of 1