HomeMy WebLinkAboutSeptic Pumping Slip - 546 FOSTER STREET 11/27/2017 Commonwealth of Massachusetts
City/Town of NORTH ANDOVER MASSACHUSETTS
z System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. The System Pumping Record must
be submitted to the local Boars! of Health or other approving authority.
A. Facility Information
Important:
When filling out 1. S yste m+qp*iqfi., r--�
farms the
computer,use J'
only the tat}key Address
to move your North Andover
cursor-do not MA 01845
use the return Citylrown State Zip Code
-
key.
2. Syst O er:
V b � .
Name
Address(if different from location)
Citylrown StaE 0
6
Telep one Number
B. Pumping Record
7. LO Date of Pumping '��`
�2, Quantit Pumped:
—
Date y p Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe): – _-
4. Effluent Tee Filter present? ❑ Yes r No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of tem:
0
6. Sypiver
By.-
�
NaVehicl License Number
Winmental
Company
�L
7. Location `s were d' osed:
or 2
(7T-
Signature of H ui'' _ Date
http://www.mass.gov/dep/water/ ati fs tmMnspec
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