HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 62 OLYMPIC LANE 10/5/2020 COMM
onwealt
h of Massachusetts RECEIVED
yt atylTowh of
System PUMPI g Record OCT -5 2020
FOim 4 TOWN OF NORTH ANDOVER
DEP has provided this form for ctse by local BoardsHEALTH DEPARTMENT
information must be substantial( the s of Health. Other forms
.local Board of Y same as That provided here.Before Using th farms but the
Health It determineoch the form they use.The System pumpingRe
the local Board of Health or other approvin
hecit with
g authority. cortl must be submitted to
Ao FacuQut�y gnfo Matl��u
important
When 8ilino out' 1_ <em o>ratTon:
fomis on the -�
computer,use
.only the tab key Address - -
to move dour f
�
cu�soF=dq-not y,
use ttie return C1ty/TOM ✓' Y '
key. -
2• System Owner, state ------
Zp Cade
ame t Gt V I S
Address(If—dtferentfrom location)
CitYlTown
state
ZI Cade
Telephone Number
Be PuMPIng Record
i• Date of Pumping _
uate 2. Quantity Pumped:
3- Type of system: �atto�
❑ Cesspool(s) �'Septic Tank
❑ Other(describe); [I Tight Tank
4. Effluent Tee Filter resent?p ❑ Yes �' No If yes, was it cleaned?
5- Condition of System: ❑ Yes ❑ No
6. System Pumped By;
Name
�t2 Trn�, �� rt S - / Vehlole L(cense Number -
Company
7. Location where contents were disposed;
Z-S D
Signature of Hauler
Date
t5form4.doc-06103 "
System Pumping Record.Page•i of 1
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