HomeMy WebLinkAboutMiscellaneous - 1607 SALEM STREET 4/30/2018 1 1607 SALEM STREET
J 210/106.6-0026-0000.0
R
Commonwealth of Massachusetts JUN 5 2006
W City/Town of NORTH ANDOVER MASSAC USETTS
H A OVER
System Pumping Record H�ALTHD! TM AlT
Form 4
G,M
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 filling out 1. System Location:
forms the
computer, use [.Q
only the tab key Address
to move your y ��/�� �� ✓���/�N
cursor-do not City/Town
use the return State Zip Code
key.
2. System Owner:
Name
Address(if different from location)
City/Town State
Telephone Number
B. Pumping Record
1. Date of Pumping Dat 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank El Tight Tank
F-1Other(describe):
4. Effluent Tee filter present? ❑ Yes Cl--No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
�i X�C Soli S 7dG!
6. System
Pumped By:
Name Vehicle License Number
Company
7. Location where contents were disposed:
z�'
SigKature of Ha Date
http://www.mass.gov/dep/water/approvaIs/t5forms.htm#inspect
t5form4.doc•06/03
System Pumping Record•Page 1 of 1
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