HomeMy WebLinkAboutSeptic Pumping Slip - 11 BRADFORD STREET 11/3/2017 Commonwealth Of Massachusetts RECEIVED
City/Town of
System Puynpulng Record NOV 0 3 2011
Form 4 'TOWN OF NOffrll ANDOVER
HEALTH 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 Sam
local Board of Health e as that provided here. Before Using this form, check With your
to determine the form they use. The System Pumping Record Must be submitted to
the local Board of Health or other approving authority,
Facl
Important;
l�fty
When filling out System Location:
forms on the
computer,use
only the tab key ...........ress /'/...........2�t"J�
to move your
cursor-do not
use the return ItY/Town
key. State
�02- System Owner: ZIP Cod
1 "I'll 1,41II
Name
ivz
n from location}
City/Town
State
ZIP Code----
.
Telephone 1v Number
B. Pump
1. Date of pumping /0 - 9- 17
-da�te 2. Quantity Pumped:
3- Type Of System: Cessl(s) Gallons
poo
0 Septic Tank 0 Tight Tank
Other(describe):
4. Effluent Tee Filter present? n yes�yl\lo If Yes, was It cleaned? 0 Yes 0 No
5. Condition of System:
•
6- System Pumped By, Rn
fume
Vehicle License Number ---------
mpany
7. Location where contents were disposed:
--------------------------
Signature of Aduter Date
t5form4.doc-06/03
System Pumping Record 4 page 1 of 1