HomeMy WebLinkAboutSeptic Pumping Slip - 10 WOODCHUCK LANE 12/4/2017 Commonwealth of Massachusetts RECEIVED
city/Town of
Sy-qtsm PUMPIng Record
TOWN OF NORTH ANDOVER
Form 4
HEAUH DEPARTMENT
DEP has Provided this form for use by local Boards of Health. Other forms may be used, but
information must be-substantially the same as that provided here. Before using this form, chethe It with your
local Board of Health to determine the form they use. The System pumping Record Must be
the local Board of Health or other approving authority, submitted to
Important;
When oiling out 1. System Location:
forms on the
computer,use
only the tab key Address
to move your
cursor-do not ru
use the return City/Town
key. state
2. System Owner: ZIP Code
'�" '�'' Address{If different from iocaiion
City/Town
State
ZIP Code
Telephone 101 le Number
B. umpl�n
I. Date Of Pumping —6—at—e I I - '7- �-7 2. Quantity Pumped.
Gallons
3• Type of system: Cesspool(s) O'Septic Tank El Tight Tank
Other(describe):
4. Effluent Tee Filter present? ❑ yes 't"
No If Yes, was It cleaned? El Yes No
5. Condition of System:
0
6. System Pumped By:
Name
Vehicle License Number
10 1<3
61611-�-
am'Cany
7. Location where contents were disposed:
Signature or Hauler Data
t6form4.doc-06/03
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