HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 30 OLD CART WAY 9/15/2012 FECF_NEo
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Commonwealth of Massachusetts oN
City/Town of NORTH ANDOVER, MASSACHUSETTEA�NOEPa�MEN
System Pumping Record "
=� Form 4
DEP has provided this form for use by local Boards of Health. The System Pumping Record must
be submitted to the local Board of Health or other approving authority.
A. Facility Information
Important:
When filling out 1. System Location:
comps on the 3 Q -
computer,use
only the tab key Address
to move your 1,.b C"_
cursor-do not City/Town State Zip Code
use the return
,key.
2. System ne 1
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
_ o
1. Date of Pumping e /S a��. Quantity Pumped:Dat Gallonss�
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Name Vehicle License Number
Company
7. Location where contents were disposed:
5 LD
W 9-�s--�
Signature of Hauler Date
http:/hvww.mass.gov/dep/Water/approvals/t5forms.htm#inspect
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