HomeMy WebLinkAboutSeptic Pumping Slip - 87 HAY MEADOW ROAD 2/20/2018 Commonwealth of Massachusetts
f City/Town of NORTH ANDOVER, MASS,ACHUSETT
System Pumping Record � �
Form 4Ca
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
Important:
When fining out 1. System Location-,
forms on the �i / )
computer,use _ / !Yl f y cat e�l
only the tab key Address
to move your
cursor-do not __..__._..._.._.. _._.___. _........__ _....,__._
use the return City[Fown State Zip Code
key.
2. System Owner: // f i
,_' i o,/2-b
Name
_ Address(if different from location)1A_
CityCTown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping [gate 2. Quantity Pumped: Gallons
3. Type of system: n Cesspool(s) " Septic Tank ❑ Tight Tank
F1 other(describe):
4. Effluent Tee Filter present? (,j Yes _ No If yes,was it cleaned? F1 Yes ❑ No
5. Condition of System.-
6. System Pumped B
27iC._
Name Vehicle License Number
---------._......,..,
Company -
7. Location where contents were disposed:
Signature of Hauler Date
http://www,mass.gov/dep/water/approvals .,forms,htm#inspect
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