HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1060 SALEM STREET 10/5/2020 C �)p �p�y'�Commonwealth Of Massachusetts RECEIVED
t atyl/ oUVI 1 OF
OCT -5 202D
Form
4system PUMP#nq Record TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
PEP has provided this form for-Use by local Boards of Health. Other f
information must be substantial( the
.local Board of Health to determine the form they use.The System forms maybe used
Y same as That provided here.Before using this fprm' but the
ur
the local Board of Health or other approving
Y Pumping Record must be submittedoto
authority.
A. fFaCHIty Owformai�i®in
Important _
hms fllllnn out
ar on the
computer,use
only the tab key Addressti
to move.�?our •* ' �� ` Sa ��>rv► S f
cur 0 do-not
use-ihe reium Ciiy/i own Cl
key_ :;► 1��;
2_ System Owner: State
p Code
ame 1 Z r
Address(ifdifierentfrom location)
City/Town
state
ZIP Code
Telephone Number
Be PUMPInQ Record
i- Date of Pumping
Date 2. Quantity Pumped; /p(��
3_ Type of system: GaJlons
❑ Cesspool(s) � Septic Tank .
❑ Tight Tank
❑ Other(descrbe):
d. Effluent Tee Fitter resent?p ❑ Yes �'No If yes,was it cleaned?
5. Condition of System; ❑ Yes ❑ No
h
6. System Pumped By:
Name
Z-e kS
Vehicle L(cense Number
Company
5 C �r C
7. Location where contents were disposed;
Signature of Hauler
Date
t5iarrn4.doc-06103
System Pumping Record.Page 7 of I
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