HomeMy WebLinkAboutSeptic Pumping Slip - 615 BOXFORD STREET 6/6/2018 Commonwealth of Massachusetts
M a City/Town of NORTH ANDOVER, IVIASSACHUSETT&U�,1 '0
System-Pumping Record , rri�n
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Form 4 .� � °^ w
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
computer,use S ' �Q✓
only the tab key Address
to move your
cursor-do not
use the return City/Town State Zip Code
key. 2. System Owner:
Name
_....__ . _____ .------
-Address
__.Address(if different from location)
city/Town State Zip Code
Telephone Number
B. bumping Record
1. Date of Pumping - / 2. Quantity Pumped:
Date 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 ❑ Na
5. Condition o ystem:
6. Sysstte`�m Pumped By:
Name Vehicle License Number
----
Company _
7. Locations�where contents were disposed:
Signature of Hauler
hftp://www.mass,gov/dep/water/approvals/t5forms.htm#jnspect
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