HomeMy WebLinkAboutSeptic Pumping Slip - 252 BOXFORD STREET 12/8/2015 _ Commonwealth of Massachusetts
--- . City/Town of North Andover
System Pumpong Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with you
local Board of Health to determine the form they use. The System Pumping Record must be submitted tc
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, �f
use only the tab 2 J '
�_. JL9fl� ._. —--- - --- -...---------.. . ._
key to move your Address -- ------- --
cursor-do not
use the return North Andover
--_—_—...___...__.
key. City/Town - State - ____..___.__...___..
Zip Code
2. System Owner: t
Name
iertan
- ---._...._.._....... ..__....__..__._..._._.. .-- -
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping - -- -- .-