HomeMy WebLinkAboutSeptic Pumping Slip - 28 FULLER MEADOW ROAD 5/21/2018 Commonwealth of Ma:3sachusettsa" �
( City/Town of NORTH ANDOVER, MASSACHUSETTS
_ System Pumping Record
Form 4 j
DBP 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 on the \ 1
computer,use
only the tab key Address
�
to move your North Andover MA 01845
cursor-do not Cit !Yawn
use the return y State Zip Code
key.
2. System Owner:
d b
"" Address(`rf different from location)---__—_..__ —__
City/Town State Zi ode
Telephone Number
B. Pumping Record
-_�1. Date of Pumping zat;04- , — 2. Quantity Pumped: Gallons ---
3. Type of system: ❑ Cesspool(s) [Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes [ No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
_ �fJ
6. System Pumped By:
Name Vehicle License Number
Wind Inver Environmental
7. Location where contents were disposed:
Haare�i�l�
40 8 POrter St
Signature of Wainer _ �– p r —•_.._
http://www.mass.gov/dep/Water/approvaIs/t5forms.htm#inspect ��c�8) (��
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