HomeMy WebLinkAboutSeptic Pumping Slip - 56 CANDLESTICK ROAD 4/23/2015 Commonwealth of Massachusetts
= City/Town of NORTH ANDOVER, MASSACHUSETTS
System Pumping Record
Form 4
�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 jV0 0M �j L,16-cursor-do not
use the return City/Town State Zip Code
key.
2. System Owner:
7y -- -
Name
tp""t Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped: Jew 0
Date allons
3. Type of system: ❑ Cesspool(s) [KSeptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ®'No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
0 A
6. System Pumped By:
4
Name V Vehicle License Number
Company
7. Location where contents were disposed:
Sigriat6re of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forrhs.htm#inspect
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