HomeMy WebLinkAboutSeptic Pumping Slip - 835 CHESTNUT STREET 12/19/2017 (2) Commonwealth of Massachusetts k�
City/Town of NORTH ANDOVER MASSACHUSETTS
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System Pumping Record syrk <R
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DEP has provided this form for use by local Boards of Health. The system Pumping Record must t
be submitted to the local Board of Health or other approving authority.
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A. Facility Information
important:
When filling out 1. Sys Location:
forms on the
computer,use �--
only the tab key Address -- --- —. _
to move your North Andover
cursor-do not MA
use the return CityCrown --- -- 0184.
key. Stake
2. System caner:
Name — — --
Address(if different from location `
City roow�n State
Telephone Number
B. Pumping record
1. Date of Pumping I
Date 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank
❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ( No If yes, was it cleaned?
i [l Yes ❑ No
5. Condition of Sy tem:
6. System uu ped By:
Nam–�
Vehicle License Number
Wind River Environmental
7. Location where.$ tFPt ,, C i *
Td
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Signature f ier Date � ---_
http://www.mass.gov/dep/waterlapprovals/t5forms.htm#inspect
t5fprm4.doc•06103
system Pumping Record•Page 1 of 1