HomeMy WebLinkAboutSeptic Pumping Slip - 1135 SALEM STREET 2/5/2018 Commonwealth Of Massachusetts RECEIVED
City/Town of
FF B 0 5 2018
SYstsm Pur ping Record OWN OF NORTH N
ADOVER
Form 4 T
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 same as that provided ided 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,
o �Facl Ift�yl nf�6,m�al I
important;
When filling out I- System Location;
forms on the
computer,use
only the tab key —Address -/—'1
to Move your
cursor-do not 4,'
use the return Clty/Town-----*-"
key. State
2. System Owner: ZIP Co—de
9
co
Cc d-- -
Name
rer 7
Address[if different from location)
CIVI—T11—wnState-——————I--------
ZIP Co—de---
Telephone Number
B. Pumping
I- Date Of Pumping
gate 2. Quantity Pumped:
3. Type of system: Gaeonsn
Cesspool(s) D Septic Tank Tight Tank
E3 Other(describe):
4. Effluent Tee Filter present? yes D No If yes, was It cleaned? Yes ❑ No
6. Condition of System: ,
6- System Pumped By:
Meme
Vehicle Llc:13 IS El Number
er
company,
7. Location where contents were disposed:
fgnature of Hau ej Date
t6form4.doc-06/03
System Pumping Record 4 page 1 of I