HomeMy WebLinkAboutSeptic Pumping Slip - 1925 SALEM STREET 9/11/2017 .°. Comrr7onwealth of Massachusetts
_ City/Town of NORTH ANDOVERC y
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. The System Pumping ust
be submitted to the local Board of Health or other approving authority.
A. Facility Information L ��
Important: `1ko C
When filling out 1. System Locatiom � p?
forms on the
computer,use
.__..---.-------_.._.___
only the tab key Address
to move your 1 ,
cursor-do not -..- ...._ _.
use the return City/Town State Zip Code
key.
2. System Owner:
Name
ra Address(if different from location)
CitylTawn State Zip Code
............... _..__._.._......._....._ __.._._..
Telephone Number
B. Pumping Record
1, Date of PumpingDa 4/ 2. Quantity Pumped: Gan ns J
3. Type of system: ❑ Cesspool(s) M Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? Yes ❑ No If yes,was it cleaned? [A, Yes ❑ No
5. Condition of System:
6. System Pumped By:
Name Vehicle License Number
Company
7. Location where contents were disposed:
Signdture,—of Hauler Date
http://www.mass.gov/dep/water/approvals/# rms.htm#inspect
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