HomeMy WebLinkAboutSeptic Pumping Slip - 70 CANDLESTICK ROAD 1/5/2015 i
Commonwealth of Massachusetts
City/Town of �'��� 6� I ANDOVER, MASSACHUSETTS
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. The System Pumping Record m f E t
be submitted to the local Board of Health or other approving authority. I
A. Facility Information
Import ant: „ I t
r `✓
When filling out 1 System Location 70 � kltl 7a,�JP
forms on the
omputer use
only the tab key Address
to move your
-�rscr do not CiryrTown State Zip Code
use the return
Bey 2 System Owner
Name
" Address(if different from location)
C ty/Town State Zip Code
Telephone Number
B. Pumping Record
1 Date of Pumping Dae i 2. Quantity Pumped Gallons
3 Type of system: ❑ Cesspool(s) [Z-��eptic Tank ❑ Tight Tank
Other tdescrlbe).
4 Effluent Tee Filter present? ❑ Yes 0—No If yes, was it cleaned? Yes No
5 Condition of System: T/T[- t tZ
6 System Pumped By: g
Name ct - - " Vehicle eLicense Nub r
Company ���f� �^ •cl (
7 Location where contents were disposed
S gne' user Date
http i/www mass gov/dep/water/approvals/t5forms htm#inspect
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