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HomeMy WebLinkAboutSeptic Pumping Slip - 1175 TURNPIKE STREET 2/6/2018 ....... Commonwealth of Massachusetts �., City/Town of � t arse is Ay e i ll GU ( tl Record TOWN OF NORTH ANDOVER ForM 4 d H ILTH DEPART NT 1 ©BP hes provided this farm for use by focal Boards of Health. Other farms may be u sed' but the information must be substantially the same as that provided here. Before usin this local Board of Health to determine the form they use. The System Pumping y the local Board of Health or other approving authority, farm,mucheck with your y p 9 Record Must be submitted to X40 Facility Information Important, When rifling out 9. forms on the System Location; h. computer,use only the tab key Address 4w_ to move your cursor-do not C/ , use the return Citynown key. (� 2• System Owner: State zip Code cit Name Address(if different from location) Citylrown State Zip Code ':7'8-iephone Number Be �ulri p! Record) I. mate of Pumping /,.". t i,. ((-- Gate Quantity Pumped: 3. Type of system: r-] Cesspaal(s ❑ Septic Tank ._._..._ga t_..TG.a anllkon°'s ❑ Other(describe): 4. Effluent Tee Filter present? ❑ yeso If yes, was it cleaned? 5. Condition of System: Yes ❑ No G. System Pumped By: Name Vehicle License Number Company 2.C' t'c' 7. Location where contents were disposed: L. 1. Signature of Hauler Date t5form4.doc-06/03 System Pumping Record 4 papa I of 1