HomeMy WebLinkAbout- Septic Pumping Slip - 39 HAWKINS LANE 5/13/2019 TOW 1`1 OF'NORI"H AMOVER
Co!mrn(")nwe,@ItI,,,i of Mda:ssaciiusetts
MASSACHUSETTS
-*vvn (,)1" NORTH ANDOVER t
W _ ��(;ia Cityffi'.)
mpno
S�13,Aenl Pti jg Record
'11
Z. NI Fc,n'in, 4
DFIP has ,pt"ovidt)d this form for se by loyal Boards of Hevilth. The System Pumping Record, must
be s ubm Itted to tile lo(;al Bo.ard of H ealth or other approving authority.
A. Fachilty Informat'i
lmportant-
Whan filling r oUt System Location-
forms on the,
compult'n',use h'.
only the tab k�ey Address
to move your North Andover MA 01845
Cursor-do not .......
GitylTown
use the return state Zip Code
key.
2. Systern
b
A�v
11 L117
Mame
arm
Address(if different trom location)
Oe
City/Town
state Zip Code
-T—eie-phonellumber—
F'U,,ll1,rIPkIq.J 14"11000-Ird
/C)1 e)of'Pumpilr`19' Date 2. Quantity Pumped, 'd-a h-O n—s
136 "I*Ype of systenil E se tic 6ranl< Tight Tank
L':1 Other(describeY
4. Effluent Tee Filter present? Yes IP
if ya's, was 11,,cleaned? Yes No
Cj*ondition of System,
arnd Vehicle 4L
lvvind PRIver Environnient,al ,M11 V"VWTP
7. Location where contents were disposed: Bradford, Ma 01835
sip t e of Date
wate r1a pp rove wass,.MrOl n s pect
t5forrn4.doc1*06103,
System Purnping Record Page I of I