HomeMy WebLinkAboutSeptic Pumping Slip - 226 REA STREET 8/6/2018 Commonwealth Of Massachusetts IRE ,SEI VED
City/` own of
' 018
Sy' lel PUMPUMg ReC(Drd TOWN OF NOFfli ANDOVER
AUG 0 6 ?
r-Orm 4 HEALTH DEPARTMENT
DEP has Provided this form for use by-loGal Boards
I triformation must be substantially the sa Of Health. Other forms May be *used, but the
00111 Board of Health to determine me as that provided here.Before using this
the local M'ne th'B fbrM they use.The System
Board of Health Or other approving authority, ' Reao Is form' Check With your
rd Must
be submitted to
ul'submitted to
A. FaclutY WOrrnatfiRn
41 Illy Dn. .
Important
When fillina ota
forms on the
QDMpUter,Use
only the tab it
ey Address
10 Move your
cursor-do not 7EI�Oft
use the return
I(ey. ------
2. SYst8mOwner
ftp Code
Ta–M—e
Address(if d%rentfrom location)
state
ZIP Code
Telephone NGrnbBr
B. PuMpIng Record
1. Date of pumping
J-
2. Quantity Pumped.,
Date V2
3. Type of system: n cesspoolm aeipticank a to n
0 Tight Tank
Other(describe).- (, (,-,
4. Effluent Tee FilterPresent? E) yes No If Yes,Was It cleaned?
5. Condition of system: ye's No
6. System Pumped By:
Name
Vehicle LiCan-80—NU—Mbs—r
CompanyZZL'CA�'- �'5e�21r–�
7. Location where contents were disposed-
olsolaturs or Hauler ------------- Date