HomeMy WebLinkAboutSeptic Pumping Slip - 550 SALEM STREET 2/20/2018 Commonwealth of Massachusetts
11 City/Town of NORTH ANDOVER, MASSACHUSETTS
System Pum'ping Record
Paan 4 � CCCt
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.
R. Facility Information _
Important:
When filling out 1. System Location: }
forms on the
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:
VQ .......... ------
Name .__,....._
Address(if different from location)
Telephone Number
----------------
B. Pumping record
1, [late of Pumping - __� 2. Quantity Ptfmped:
Date Gailons
3. Type of system. ❑ Cesspool(s) 19<0ptic Tank ❑ Tight Tank
Other(describe): ___.._..-------- _ _.__- ......__.._._
4. Effluent Tee F=ilter present? ❑ Yes No If yes, was it cleaned? ❑ Yes C No
5. Condition of Systern:
r�
6. System Pumped By:
7/C-
Name Vehicle License Number
_..._....._,.._-._
..._... — ------
Company
7. Location where contents were disposed:
Signa ure of Hauler Date
http://www,mass.gov/dep/water/approv±s.hLsp-ec--t---------
t5form4.doc-
06/03 System Pumping Record•Page 1 of 1