HomeMy WebLinkAboutSeptic Pumping Slip - 50 WILLOW RIDGE ROAD 12/4/2017 Commonwealth of Massachusetts ECC IVED
City/ 'own of
V�
SYst8m Pumping Record
Form 4 -�'OVVN OF NORIIA ANDOVER
DEFAFUMENT
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.
Important;
When filling out 1. System Location:
forms on the
computer,use
S D
only the tab key dress
to move your
cursor-do not
use the return City�/Town
key. Stats
2. System Owner: ZIP Code---
Name
Address(if dlfferen#from locaEion)
ism Qy
CIWI—Tow—n
Skate
ZIP Code
Telephone Number
�Pum�ping�Reco�rd
Date Of Pumping
2. Quantity Pumped.
3. Type of system: Cesspool(s) ....... Daltons
11" Septic Tank" Tight Tank
Other(describe):
4. Effluent Tee Filter present? [] Ye�'
Nq) If yes, was It cleaned? 11 Yes No
5. Condition of System:
6- System Pumped By:
Name
Vehicle License N—u—mb—er-----------
Com pany C,1=41 t
7. Location where contents were disposed:
/I " "'
Z—� 13
�el
Signature of auler Date
t6Jbrm4.doc-06/03
System Pumping Record-Page 1 of I