HomeMy WebLinkAboutMiscellaneous - 274 ForestCommonwealth of Massachusetts
City/Town of NORTH ANDOVER, MASSACHUSETTS
System Pumping.Record
Form 4
DEP has provided this form for use by local Boards of Health. Thel
be submitted to the local Board of Health or other approving autho
A. Facility Information
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key. . 2.
nrest 6kee-V
Add
77) - & c�jnvc r
Cityrrown
VOW% Fn ip� cord Inust
OWN OF NORTH ANDOVrR
HEALTH
M� -
State Zip Code
Name
Address (if different from location)
Cityfrown State Zip Code
Telephone Number
B. Pumping Record
I Date of Pumping .3b_51_16
Date 2. Quantity Pumped
3. Type of system: Cesspool(s) Septic Tank
-C Other (describe):
4. Effluent Tee Filter present? E] Yes F] No
5. Condition of System:
I
Gallons
Tight Tank
If yd,*Was it cleaned? El Yes n No
6. ystem Pumped By:
Vehicle License Number
(Two. aj, �-�Clc sc#w e�
Company
7. Lpcation where contents were disDosed;
0
J'Signature of Hauler —
http:/twww.mass.gov/deptwater/approvals/t5forms.htm#inspect
t5form4.doc- 06/03
Date
n 11
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System Pumping Record - Page 1 of 1