HomeMy WebLinkAbout- Septic Pumping Slip - 43 FULLER ROAD 12/12/2018 Commonwealth of Massachusetts
City/Town of NORTH ANDOVER., MASSACHUSETTS
System Pu
mping ump6ng Record
Form 4
H
DEP has provided this form for use by local Boards of Health. The System Purnping 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
p
Co' Ute6,use
only the tab key
Address
to move your
cursor-do not
use the return City/Town State Zit]Code
key.
2. System Owner:
Name �... —.
Address if different from location --
ity/Towm State Ti,Code
r"elephone Number
B. Pumping Record _.
1. Date of Pumping r .: "/ ' —_�`� , t,p� g ..—._ — �._.. 2. Quantity Pumped,-
Date - -._.—..._
Gallons
3. Type of system: Cesspool(s) El'Septic Tank (_] Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? E] Yes 0-'No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Name Vehide License Number-__,___ --- --.,.
Compar7y
7. Location where contents were disposed:
c;
1
_.
Signature of Ftauler Date
http://www.mass.gov/dep/water/approvals/t5fortns.Pitm#inspect
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