HomeMy WebLinkAboutMiscellaneous - 66 COLONIAL AVENUE 4/30/2018 (16) Commonwealth of Massachusetts
City/Town of I RECEIVED
System Pumping Record OCT 2 4 2006
Form 4
TOWN OF NORTH ANDOVER
DEP has provided this form for use by local Boards of Health. Th must
be submitted to the local Board of Health or other approving authority. .
A. Facility Information
Important:
When filling out 1. Syst m Location: �r
fomes the
computer,use
ze—
only the tab key Address
to move your
cursor-do not
use theretum Cityrrown State Zip Code
key. 2 System Owner:
IC Iy 4; `
Name
ISI Address(if different from location)
Cityft"own State Zip Code
Telephone Number
B. Pumping Record
1. Date of m in _
.Pup g Date 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe).
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of Systerp��
(A,
6. System Pu , ped 6
C c Cr _
Name Vehicle License Number
Company
7. Location ere ontent re di sed:
Signaturof u r Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
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