HomeMy WebLinkAbout- Septic Pumping Slip - 114 BOXFORD STREET 12/12/2018 Commonwealth of Massachusetts
City/Town of NORTH ANDOVIER MASSACHUSETTS
W System Pumping Record
d
Form 4 1
DEEP has provided this form for use by focal Boards of Health. The System Pump ing,Record must
be submitted to the local Board of Health or other approving authority. . _
A. Facility Information I r( f —
Important:
When filling out 1. System Location:
forms onthe
computer,use
only the tab key Address
to move your
cursor-do not
- �' '' `
use the return City/Town State Zip Code
key.
2. System Owner:
Nan)e
Address(if different from location)
Gity/Tawn
State _..-.. _
7rp Coc1e
Telephone Number
B. Pumping Record
1. Date of Pumping ...
p 9 Date
�....—_...,._ 2. Quantity Pumped: .,._— _._��......_.
Gallons
3. Type of system: ❑ Cessppol(s) eptic Tank [] Tight Tank
[� Other(describe):
4. Effluent Tee Filter present? ❑ Yes �]''No If yes, was it cleaned? ❑ Yes No
5. Condition of System:
5. System Pumped By-,
Name Vehicle License Number
7. Location where contents were disposed:
C J"
' =la= Z..—" - --- d r .-_._ 40 J y Y
Signature of Frauler Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#irispect
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