HomeMy WebLinkAbout- Septic Pumping Slip - 501 BOXFORD STREET 12/12/2018 Commonwealth of Massachusetts
' == City/Town of NORTH ANDOVER MASSACHUSETTS
S stem Pu
mping umping 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:
When filling out 1. System Location:
forms on the
computer,use _. �'� <'z- `ram,
only the tab key
to move your
cursor-donot L `�
use the return City/Town State Zip Code
key,
2. System Owner:
v4Di11. t'1
Name
n�rn
Address(if different from location)
CitylTown State Zip Cade
Telephone Number
B. Pumping Record -
1. Date of Pumping — .--.__�_ ? Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) ['Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? EKYes ❑ No If yes, was it cleaned? ❑"Yes ❑ No
5. Condition of System:
6. System Pumped By:
61
Name
Vehicle License Number
Company
7. Location where contents were disposed:
Signature of Hauler SJ � Date__.`
http://www.mass.gov/dep/water/appr6vals/t5forms.htrii#inspect
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