HomeMy WebLinkAboutSeptic Pumping Slip - 106 BOSTON STREET 12/18/2015 (2) mm®nwOelth of Massachusetts
own ypf NORTH ANDOVER MASSA
System Pumping Record
Form 4
a
DEP has provided this form for use by local Boards of Health, T d `ti l r+ "`' 'i1ri 1n' e`c{8d mu:
�; 0",1 '�
be submitted to the local Board of Health or other approving autcr' -
A. Facility Information -
Important:
When filling out 1. System Location;
forms on the
computer, use
only the tab key Address
to move your
cursor-do not
use the return Clty/Town
Stale — Zip Code
k�ey''�j 2. System Owner
Name -
_ .__.-_.._.__ _._.___--•-----..._.._..._._- ------
Address(it different from location)
City own State �Z' ode
Telephone Number
S. Pumping Record - `- --
Date of Pumping `'
p g Dat 2. Quantity Pumped;
Gallpns
3, Type of system: ❑ Cesspool($) 09MItic Tank ❑ Tight Tank
❑ Other(describe): -..–._._—........
_.___...__._..----.__._____.—,...-_---.__.__.___._.__.__.___.............__.
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes
5. Condition of System: y
1
Sy em Pumped By:
ame Vehicle License Number
c5t _a
Company
7. Location where contents were disposed;
ature of Hau Dale
http;//www,masg,,gov/dep/water/ provals/t5forms,htm#inspect
t5form4.doc,06/03 System Pumping Record -Page i of
1
Com' monwoalth of Massachusetts (� °�.
City/Town of NORTH ANDOVER MASSA FiUi `f-
ysterrll Pumping Record `TtW 0 NCR*HANDB t
Farm 4 t�6AtwTIt ErARTn� NT
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 10G ,
y
only the tab key Address l
to move your
us
use the returnt City/Town State Zip Code
key,_. 2, System Owner:
Name
Address(If different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1, Date of Pumping Date 2• Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Ueptic Tank ❑ Tight Tank
-4-1 Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, it cleaned? ❑ Yes ❑ No
5, Condition of System:
1 1
6. S stem Pumped By:
C
e � �r <,-") Vehicle License Number
g �(_
Company
7. Location w ere contents were disposed:
P)
`� I,�
l' /I , ; .
l
o
S ature of Hauler Date
http://www.mass,g//deptwater/approvals/t5forms.htm#inspect
t5form4.doc-06/03
System Pumping Record-Page 1 of 1
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provided
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e submi�ed to
the Iocal Board of Health or other approving author)
A. Facility Inforrtlon --
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ght Tan
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