HomeMy WebLinkAboutSeptic Pumping Slip - 16 HALIFAX STREET 12/28/2015 I
Commonwealth of Massachusetts t
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City/Town of NORTH ANDOVER, MASSACHUSETTS j
System Pumping Record
Form 4
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f
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 16 HALIFAX ST
computer, use
only the tab key Address
to move your N.ANDOVER MA 01845
cursor-do not City/Town State Zip Code
use the return
key. 2. System Owner:
MARY KELLY
Name
' Address(if different from location)
City/Town State Zip Code
978-852-3850
Telephone Number
0 t
B. Pumping Record
1. Date of Pumping Date 03/04/15 2. Quantity Pumped: 1,000
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
GOOD
6. System Pumped By:
ROGER ROBEY 7626AR
Name Vehicle License Number
SOUCY SEWER SERVICE INC
Company
7. Location where contents were disposed:
G.L.S.D.
Signature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
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