HomeMy WebLinkAboutSeptic Pumping Slip - 638 FOREST STREET 5/21/2018 "�
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Commonwealth of Massachusetts \ 1" .. O '
a - C City/Town of NORTH ANDOVER MASSACHUSETTS
3 System Pumping Record
Form 4
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DEP has provided this form for use by local Boards of Health. The System Pumping Record must 1
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 '" c
computer,use
only the tab key Address - — -- ----_-- —_.
to move your North Andover _MA 01845
cursor-do not — __ _
use the return City/Town —_ _...._ State Zip Code
key.
2. System Own r:
b ,
''
Nam� _e
Address of different from location)
City/Town
Slate.• _�
Telephone Number ✓B. Pumping Record
1. Date of Pumping D— -- -- 2. quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes tO No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of Systa
6. Systenj?ped
Vehilcl License Number
Wind River Environm 1
7. Location where con Iw s ��
Signature of Houle
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
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