HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 64 NORTH CROSS ROAD 11/23/2020 Commonwealth of Massachusetts
City/Town of , , RECEIVED
System Pumping Record Nov ?_ 3oZo
Form 4 TOWN OF NORTH ANDOVER
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DEP has provided this form for use by local Boards of Health. Other fomns may be used, but�e-
information must be substantially the same as that provkted here. Before using this form, ► with your
local Board of Health to determine the form they use.The System Pumping Record must be submitted to
i the local Board of Health or other approving authority within 14 days from the pumping date io
accordance with 310 CIWR 15.351.
A. Facility Information
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VNren 1. System Location:
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2. System Owner.
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Address(N Of omw from bcraon)
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Clly/rown sude
Zip Code
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Telephone Number s
B. Pumping Record
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1. Date of Pumping Dale �� 2. Quantity Pumped: Gallon
3. Component. ❑ Cesspool(s) ❑Septic Tank ❑ Tight Tank
' Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it deaned? ❑ Yea ❑1 Nd,
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5. Observed condition of component pumped:
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6. System Pumped By: j
Name Vehfde Lk ense Number
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7. Location where contents were disposed:
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I Slpnahrre of Weuler Dale
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i Slpnahue of ReceWft FadYly(or attach kwft receipt) Dare
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