HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 271 BARKER STREET 10/4/2023 Commonwealth of Massachusetts
y MA/Town �EPARTiV1�NT
City/Town of NORTH ANDOVER,
System Pumping Record OCTF: 04 2023
r� 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:
forms on the
... .......
computer,use ---
only the tab key Address
to move your Byejz_
cursor-do not CityfTown State Zip Code
use the return
key.
2. System Owner: C
Name
Address(if different from location)
CityfTown State - Zip Code
Telephone Number
B. Pumping Record - -
1. Date of Pumping �� —`�3 2. Quantity Pumped: Gallons
Date
3. Type of system: (] Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe): — -
4. Effluent Tee Filter present? ❑ Yes LJ No If yes, was it cleaned? Yes ❑ No
5. Condition of System:
6. System Pumped By: c
Name "�7' Vehicle License Number
Company - — —
7. Location where contents were disposed:
Signature of Hauler --- Date
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