HomeMy WebLinkAboutSeptic Pumping Slip - 153 HAY MEADOW ROAD 2/20/2018 1-, Commonwealth of Massachusetts
rAll City/Town of NORTH ANDOVER, MA SACHU5
1 = System Lumping Record
1 Form 4
DEP has provided this form for use by local Boards of Health. The System rcl must
be submitted to the local Board of Health or other approving authority.
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A. FacilityInformation
Important:
When filling out 1. System Location:
forms oilthe
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cornputotcr,use '� � `�A' �o!� �`'-
only the tab key Address
to move your
cursor-do not _...._ _............._.._ _,__.._ ___
use the return City(Town State Zip Codes '
kc:y.
2. System owner:
Name _._._.....__..._... ..— _..a__._
'A-5. Address(if different from location)
City[Town State lip Code
Telephone Number
B. Pumping Recon
1. Date of Pumping / 2. Quantity Pumped: f
Date Gallons
3. Type of system: F1 Cesspool(s) L--j--Septic
_; Septic Tank ❑ Tight Tank
❑ other(describe):
4. Effluent Tee Filter present? El Yes No If yes,was it cleaned'? [] Yes ❑ No
5. Condition of System:
6. System Pumped By:
Name Vehicle License Number
Company
7, location where contents were-disp used:
Signa 6e of Hauler � � Date
i
http://www.m<ass,gov/dep/water/approvals ajorms.htrnffinspect
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