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HomeMy WebLinkAboutSeptic Pumping Slip - 174 CANDLESTICK ROAD 6/6/2018 _ Commonwealth of Massachusetts City/Town of NORTH ANDOVER, MASSACHUSETTS System Pumping Record Form 4 a DEP" 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: / ❑} "JUN When f6ling out 1. System �oC.._. C?._ J . � ....._. y _. _.__..._„ tSti � Location: _ forms on the v TOWN O C�d�i i��� F�y��°'f� computer,us© only the tab key Address to rnove your cursor-do not ._�_.._._. _..._. ---.._..__ use the return City/Town State Zip Code key. 2. System Owner: _ la. Name _- ..._,. _........_. " Address(if_different from_location) _Statei�e-_.._..._.._ Z _....w._ ___,�_C.ade City/Town _. Telephone Number B. Pumping Record 1. Date of Pumping t:57 3 ©ate __ --- 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) L 7 Septic Tank ❑ Tight Tank ❑ Other(describe): ......_. 4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? [_] Yes ❑ No 5. Condition of System: tom- a-0 cx 6. System Pumped By: i3d ,° i 2.t!! e Name Vehicle License Number Company 7. Location where contents were disposed. Signature of Hauler Date http://www.mas8.gov/dep/water/approvals/t5forms.htm#inspect I t5form4.doc•06/03 � System Pumping Record Page 1 of 1