HomeMy WebLinkAboutSeptic Pumping Slip - 150 BRIDGES LANE 2/20/2018 `. Commonwealth of Massachusetts W
City/Town of NORTH ANDOVER, MASSACHUSETTS.. . 'g)�b
System Pumping Record mm. �Form 4
���.
100k 06N
DEP has provided this form for use by local Boards of Health. The System Pumping Record must
be submitted to the local Board of Health or other approving authority.
A. Facility Information
trnportant:
When filling out .1. system Location:
forms on the `
computer,use
only the tab key Address '
to move your
cursor-do riot
use the return CitylTown State Zip Code
key.
2. System Owner:
Name
Address(if different from location)
C ityfrown _ ..,_..,_ — State Zip Code
Tr;4ephone Number
B. Pumping Record
eb
1. Date of Pumping Dale
-r.- _._ — 2. Quantity Pumped: ��'
Gallons
3. Type of system: ❑ Cesspool(s) ( septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent"T"ee Filter present? ❑ Yes .-__ No If yes,was it cleaned? Yes No
5, Condition of System:
i
i
6. System Pumped By:
Name Vehicle License Number
Company
7. Location where contents were disposed:
�•�r�, /-
Signalurc of I iauler Date
http://www.mass.gov/dep/water/approvals forms.htm#inspect
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