HomeMy WebLinkAbout- Septic Pumping Slip - 762 DALE STREET 12/12/2018 Commonwealth of Massachusetts
City/Town of NORTH ANDOVER, MASSACHUSETTS
System Pumping Record
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Form 4 }
Dr-P 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:.
When filling out 1. System Location:
forms on the
computer,use
only the tab key Address
to move your
cursor-do not
crown .-_— ..—
use the return Cit y State Zip Code
key.
2. System Owner-.
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Name
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Address(if different from location)
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State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2- Quantity Pumped:
t7ate Gallons
3- Type of system: ❑ 11
Cesspool(s) ❑"Septic Tank ❑ Tight Tank
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Other(describe):
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4. Effluent-fee Filter present? ❑ Yes [] No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
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—„ ILL/
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Name _
Vehicle License Number
Company
7. Location where contents were disposed:
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-_
Signature of Hauler Da{e
http://www.mass-gov/dep/water/appro'vals/t5forms.htm#irispect
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