HomeMy WebLinkAboutMiscellaneous - 204 Carlton Lac
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Form 4MY I TOWN ol' NORTH ANDOVER
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
DEP has provided this form for use by local Boards of Health I IOUE LTI
be submitted to the local Board of Health or other approving authority.
A.. Facility Information
1. System Location:
On rau) lan-e.
Address ^
City/Town State Zip Code`
2. System Owner. c
%1
Name '" 1
Address (If different from location) \ J
City/Town
State Zip Code
Telephone Number
B. Pumping Record
sk//
1. Date of Pumping Date o 2. Quantity Pumped: Gallons
3.. Type of system: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank
'' -�( Other (describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No
5. Condition of System:
6. Sxstem Pumped By:
If yes~was it cleaned? ❑ Yes ❑ No
O-e.h I.
e Vehicle License Number
-ft
S 1C - "er�t�C
Company e -
7. Location where contents were disposed:
rd must
Signature of Hauler Date
http:/twww.mass.gov/deptwater/approvals/t5forms.htm#inspect
t5forrn4.doc- 06/03 System Pumping Record • Page 1 of 1