HomeMy WebLinkAboutMiscellaneous - 24 Bridle Path RoadI
Commonwealth of Massachusetts
City/Town of NORTH ANDOVER MASSAC
4=12 ED
System Pumping Record
•` Form 4
- 9 2010
DEP has provided this form for use by local Boards of Health. Thd, S stem Pumppin RecorT I
be submitted to the local Board of Health or other approving auth rii WN OF NORTH RNDbVER
'HEALTH DEPARTMEN'i
Yf fpr
Name
Address (if different from location)
City/Town
Vl • C1lf�
State Zip Code
State
Telephone Number
Zip Code
B. Pumping Record
20a 1600
1. Date of Pumping Date / 2. Quantity Pumped: Gallons -
3. Type of system: ❑ Cesspool(s) 2 Septic Tank ❑ Tight Tank
Other (describe),
4. Effluent Tee Filter present? ❑ Yes ❑ No If ye§; was it cleaned? ❑ Yes ❑ No
5. Condition of System: AW 3 .
6. S em Pump By:
-`' hZ
Name Vehicle License Number
Company
7.
http:/Avww.mass.gov/depAvater/approvalstt5forms.htm#inspect
t5form4.doc- 06/03
System Pumping Record • Page 1 of 1
A. Facility Information
Important:
When filling out
1. S stem Location:
forms on the
1
computer, use
Q
only the tab key
move yourcursor
4Adddrrosto
- do notuse the returnwn
key...
43
2. System Owner:
nrlanU-v
Name
Address (if different from location)
City/Town
Vl • C1lf�
State Zip Code
State
Telephone Number
Zip Code
B. Pumping Record
20a 1600
1. Date of Pumping Date / 2. Quantity Pumped: Gallons -
3. Type of system: ❑ Cesspool(s) 2 Septic Tank ❑ Tight Tank
Other (describe),
4. Effluent Tee Filter present? ❑ Yes ❑ No If ye§; was it cleaned? ❑ Yes ❑ No
5. Condition of System: AW 3 .
6. S em Pump By:
-`' hZ
Name Vehicle License Number
Company
7.
http:/Avww.mass.gov/depAvater/approvalstt5forms.htm#inspect
t5form4.doc- 06/03
System Pumping Record • Page 1 of 1