HomeMy WebLinkAboutSeptic Pumping Slip - 525 BOXFORD STREET 9/11/2017 Commonwealth of Massachusetts
-r�a City/Town of NORTH ANDOVER, MASSACHUSETTS
System Pumping Record
Form 4
-s_
DEP has provided this form for use by local Boards of Health. The System Pumping Recor st
be submitted to the local Board of Health or other approving authority.
A. Facility Information t �.
wh n cling out 1. System Location: D ` D
forms the
computer,use
only the tab key Address
to move your / -
cursor-do riot -.- .._..._.. y _. .._ _-___- ___ _.._.___ __-
use the return City/Town State Zip Code
key. 2. System Owner: /
teb _❑F//Lr l;;. Gil,
Name
' ' Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Dake Gallons
3. Type of system: ❑ Cesspool(s) 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:
(;C a
6. System Pumped By:
❑� .yrz.l l i
Name Vehicle License Number
Company
7. Location where contents were disposed:
Sig iauler Date
j
http://www.mass.gov/dep/water/approvals,/t5f s.htm#inspect
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