HomeMy WebLinkAboutSeptic Pumping Slip - 849 DALE STREET 2/20/2018 aCom' monwealth of Massachusetts
! � j � City/Town of KORT ANDOVER, A ACHUSETT
RSystem Pumpingecordvilb
Farm 4 °..
kA
DEP has provided this form for use by local Boards of Health. The System Pumptnc mast
be submitted to the local Board of Health or other approving authority.
A. Facility Information
Important:
When filling out t System Location:
forms on the
computer,use O C
------------------
only the tab key Address
to move your
cursor-do not ___,_,_... w.._ __
use the return Cityfrown State Zip Code
key. 2. System Owner-
co( Yl M r3!ur
___ _
Name __�.._....__.
"— --- Address(if different from location)
C.ity(Town State Zip Code
Telephone Number
B. Pumping Record
M .
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) [�eptic Tank �_� Tight Tank
(_] Other(describe):
4. Effluent Tee Filter present? F Yes [TNo If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By.,
Name Vehicle License Number
i
Company — ---
7. Location where contents were disposed:
r
Signai-ure of Hauler Date
1
trttp://www.mass.gov/dep/water/approvalsaforms.htrn#inspect
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t5form4.docc 06/03 System Pumping Record•Page 1 of 1