HomeMy WebLinkAboutSeptic Pumping Slip - 126 PHEASANT BROOK ROAD 4/4/2018 COMmonwealth Of Massachusetts RECEIVED
M
City/Town of &-fivoov(�-
Pumping Record
L APR 04 ?016
Form 4
TOWN Or,NORTH ANDOVER
HEAIXti DEPARTMENT
DEP has provided this form for use by local Boards of Health. Oforms mabe '
information must be substantially the same as that provided here.ther Before using y this Used, but the form, ch
local Board of Health to determine the form they use.The System Pumping
the local Board of Health or other approving authority. Record must beeck with your
-submitted to
Important;
When fliancr out I- System Location;
forms onthe
computer,use 4
Only the tab key Address
to move your
cursor-do not
use the return tlly/I own
key. State
2. Systerrr,gwner: ZIP C-0—de---
AC4
Name
"VAI
Address(if dffferen#from 1pcatlon}
Cfty/�Town
lq�State ZIP C—od-e--
elep one Number
B. i umping
I- Date of Pumping
2. Quantity Pumped: Ls
3- Type of system: n C,,,,p Gallons
El 001(s) 4Septic Tank Tight Tank
Other(describe):
4. Effluent Tee Filter Present? [] Yes
/ET'No If Yes, Was It cleaned? Yes No
5. Condition of System: ,
6. System Pumped By:
f3
-Name Vehicle License Number ------
ze-
Company
7. Location where contents were disposed:
I ur ofa—u I
er Date
V=4.doc-06/03
System Pumping Record n page 1 of I