HomeMy WebLinkAboutSeptic Pumping Slip - 50 BOXFORD STREET 2/20/2018 LL� Commonwealth of Massachusetts RECEIVED
ROOM
City/Town of NORTH ANDOVER iASSACHUS
1
_ ) System Pumping Record 0 pj4OOVER
Form 4 low
DEP has provided this form for use by local Boards of Health. The System Purnping Record must
be submitted to the focal Board of Health or other approving authority.
A. Facility Information
I
Important:
Men filling out 1. System Location:
forms the y �e I Poe d .
computer,use .................._ _..___..� .,.._.
only the tab key Address
to move your
cursor-do not _...._._..._. _,_,....._ _..._, ...._._ —__------ ---...,.
use the return City/Town State
Zip Code
key.
2. System Owner:
rye /3rhJt'car 1 f*ly) 'Yl
Name __._..
° '_� Address(it different from location)
Cit (sown
Y Stale lip Code
Telephone Number
B. Pumping Record
1. bate of Pumping -ply - 7. - 2, CAuantity Pumped:
Gallons
3. Type e of system:y ❑ Cesspool(s) [_ Septic Tartk El Tight Tank
( ] Other(describe): _ _..._..
4. Effluent'l-ee Filter present? Ll Yes /- No If yes,was it cleaned? E] Yes 0 No
5. Condition of Systerr7: f
1 CL
6.. Systerri Pumped By:C
Name 1 Vehicle License Number
Company ._._.....
-7. Location where contents were disposed:
G-! S,
Signa'Tiaec of Hauler pate
http://www.mass.gov/dep/water/approvals t forrns.htm#inspect
t5form4.doc-06/03 System Pumping Record-Page 1 of 1