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.
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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
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ravorn Address(if different from location)
City/Town State Zip Code
Telephone Number
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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:
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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
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