HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 126 PHEASANT BROOK ROAD 7/7/2020 -- - Commonwealth of -------. ---. __----
City/Town o
Massachusetts RECEIVED
Systsm Pumping Recur oo JUL 0 7 ?.020
Form 4 TOWN OF NORTH ANDOVER
DEP has provided this form for use by Local Boards of Health. Other forms HEALTH DEPARTMENT
information must be substantially the same as that provided here. Before usin
local Board of Health to determine the form they use.The System Pumping
maybe used, but the
the local Board of Health or other approving9 this form, checit with your
authority. p Record must be submitted to
�e FacuBu��y �Q�3�oB'l1�latloni
Important:
When filling out 1_ •atgrn t-dicttior]:
Forms on the
computer,use
only the tab key Address
to move.y�our
cursoe-'do-not
use the return CitylTown G .-
key. State
2- System Owner: zip Code
Name GL�D r'1 S rn
7ddrei—nff dffferentfrom location)
y/Town
State Zip Code
Telephone Number
1- Date of Pumping
Date — -- 2. quantity Pumped: /$�
3. Type of system: Gallons
❑ Cesspool(s) Septic Tank -
❑ Tight Tank
El Other(describe):
4. Effluent Tee Filter resent?p ❑ yes ( No If yes, was it cleaned?
Yes No
(] ❑
5. Condition of System: ti
6. System Pumped By:
Name
R� Vehicle Ucense Number
parry SSA( Ze lk S 5 C- -fir C
[.ompany ,
7. Location where contents were disposed:
L
Ssgnature of Hauler
Date
t5form4.doc-06103
system Pumping Record.Page-I of 1
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