HomeMy WebLinkAboutMiscellaneous - Exception (132)Commonwealth of Massachusetts RECENE
"City/Town of, NORTH ANDOVER MASSACHUSFTTS
System Pudping Record FEB 2006
Form 4
TOWN OF NORTH ANu`
U9 , HEALTH DEPARTMENT
®EP has provided this form for use by local Boards of Health. The System Pumping ftec
be submitted to the local Board of Health or other approving authority.
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
mann
A. Facility Information
1. System Location:
Address
City/Town
2. System Owner:
Address (if different from location)
City/Town
1. Date of Pumping
3. Type of system: ❑
❑ Other (describe):
St to e!%�
State
Telephone Number
Date 2. Quantity Pumped
Cesspool(s) EKSeptic Tank
Zip Code
Zip Code
must
❑ Tight Tank
4. Effiuent.Tee Filter present? ;❑ Yes,,[]-No--_If.yes, was -it -cleaned? ❑ Yes ❑ No
5. Condition of System:
6. 4,Syem Pumped B
Vehicle License Number
Company
7. Location where contents were disposed:
D
Signature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
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