HomeMy WebLinkAboutSeptic Pumping Slip - 1580 SALEM STREET 9/11/2017 Commonwealth of Massachusetts
City/Town of NORTH ANDOVER., C ` -
System Pumping Record
Farre 4
DEP has provided this form for use by local Boards of Health. The System Pumpingµ eco�rd:, st
be submitted to the local Board of Health or other approving authority.
A. Facility Information
Important: Q
When filling out 1. System Location: t� p
forms on the
computer,use
only the tab key Address
to move your
cursor-do not
use the return City/Town State Zip Code
key. 2. System Owner:
VQ
__.._
4r 'e,I
Name
r�vo Address if 1.diffe1.re11 nt from location)
City/Town State Zip Code
Telephone Number
___--_--------______..._.___---
B. Pumping Record
'7 � S
1. Date of Pumping —..._.____....._....._. 2. Quantity Pumped: -- ---
Date Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank F1 Tight Tank
❑ Other(describe): — __ .____ __._..... ... ......... .....__
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
_____ _.__ G �1 _._ - _ _ _
6. System Pumped By:
Name Vehicle License Number
Company
7. Location where contents were disposed:
°7
Signe t> of Hauler Date
http:f/www.mass.gov/dep/waterJapprovals/t5forms,htm#inspect
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