HomeMy WebLinkAboutSeptic Pumping Slip - 203 BOXFORD STREET 10/4/2017Important;
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Commonwealth of Massachusetts
City/Town of
System Pumpin Hecord
Form 4
OC 4 2011
OF NORTH ANDOVER
LTH DEPARTMENT
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. F cility flt for; a 10
1. System Location:
City/Town
2. System Owner:
Address (if d
City/Town
en
Zip Code
location)
Pumping Record
1. Date of Pumping
3. Type of system: D CesspooI(s)
El Other (describe):
4. Effluent Tee Filter present? 124-Y-es El No
5. Condition of System:
6. System Pumped By:
Name
Telephone Number
------- 2. Quantity Pumped; Dale
Gallons
[D<Itic Tank El Tight Tank
racie k :S
Company
7. Location where contents were disposed:
L 1'
If yes, was it cleaned? 113--Y/es ED No
Vehicle License Number
&67(.7.7
Signature of Hauler
Date
t5form4.doc• 06/03
System Pumping Record • Page 1 of 1