HomeMy WebLinkAboutSeptic Pumping Slip - 773 WINTER STREET 2/20/2018 Com, monwealth of Massachusetts
� MM
4 City/Town of NORTH ANDOVER WASSACHUSET
System Pumping ecord �
Form v .
DEP has provided this form for use by local Boards of Health. The System Pumpecord mast
be submitted to the local Board of Health or other approving authority.
A. Facility Information
Important:
Mier)filling out 1. system Locution:
forms ori the
computer,use
only the tab key Address
to move your
cursor-do not __..__....
_m...,
use the return City/Town State Zip._Cad._..e—.,,_
key.
2. System Owner:
Mame —...._._�_.,._
6_1 _
Address(if different frarn foci#ion)
i
._....—..
Citylrown State "l--.. �ip Cade _—.
Telephone;Number
B. Pumping Record
1. Gate of PumpingDate�� / 7 – 2. Quantity Puh7ped:
Cxauans
3. Type of system: ❑ Cesspool(s) Septic Tank [] Tight T=ank
El Other(describe):
_.r
4. Effluent Tee Filter present? Yes DINO If es was it cleaned„?_.— -- Yes
5. Condition of system: -/
C.J. _....-.-.. .._._....._ ......._.-___
6. system Pumped By.
�1
Name Vehicle License Number
Company --
i
7. Location where contents were disposed:
SignAjre of t-lauler pate
fittp://www.mass.gov/dep/water/approvals ,`forms.htm#tinspect
t5form4.doa 06103 system Purnping Record•Page 1 of 1