HomeMy WebLinkAboutSeptic Pumping Slip - 115 CARLTON LANE 2/20/2018 Commonwealth of Massachusetts
N'-- City/Town of NORTH ANDOVER, MASSACHUSETTS
�} System Pumping Record
Form 4
�� . 'D
DEP has provided this form for use by local Boards of Health. The System Pun1�i �r �t
be submitted to the local Board of Health or other approving authority. CDP "
A. Facility information
Important:
When filling out 1. System Location, /
forms on the �- �—~ Co a,17-oov 0�/3 if✓�
computer,use
only the tab key Address
to move your
cursor-do not __.— _,_._.—_.. .. .----....-. State Zip Code
use the return C-ityfrown
key.
2. System Owner:
3
Name
--------
_._.-
Tr 'lin Address(if different from location)
..._..own State Zip Code
CityfT
Telephone Number
B. Pumping Record
1. Date of Pumping — }`/ .._ .__...... 2. Quantity PuGallonscn
mped: _ anon
Dates
3. Type of system: ❑ Cesspool(s) [._ Septic Tank ( Tight Tank
Other (describe): _.--
4. Effluent Tee Filter present? ❑ Yes [m Na If yes,was it cleaned? U Yes ❑ filo
5. Condition of System:
C. Systern Purnped By:
an7e Vehicle t icense Number
i
Company
I f_.ocation where contents were disposed:
/}
SignaTure of Hauler bate
http://www.mass.gov/dep/water/approvals f farm: rn##inspect
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