HomeMy WebLinkAbout- Septic Pumping Slip - 326 FOSTER STREET 12/10/2018 Commonwealth of Massachusetts
City/Town of NORTH ANDOVETT
System Pumping Record
Form 4
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: :,,',
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use the return ity/Town State Zip Code
key. 2. System Owner:
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Name --.._.__ __.,.___
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City/Town .Stater ZipCe.,
Telephone Number
B. Pumping Record
1. Date of Pumping ° 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? [l Yes ❑ No
5. Condition of$ry ern:
ti' f
6. System P �ed,$y.
C/ (60
Name Vehicle License Number
Wind River Environments
CompanykAl
7. Location where cont n e ose
Signature of r Date
http://www.mass.gov/dep/water/appr r s.htm#inspect
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