HomeMy WebLinkAboutSeptic Pumping Slip - 315 SOUTH BRADFORD STREET 1/1/2012 Commonwealth of Massachusetts
City/Town of
System Pumping Record NORTH ANDOVER
.ti
- 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 your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
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 I• System Location: �
forms on the
computer,use
only the tab to move not Address
cursor do _. State Zip Code
use the return Gity(Town
key. 2 System owner:
VQ
Narne
�° Address Qf different from location)
— Slate
City/Town Zip Code
Telephone Number _
B. Pumping Record -- ----
.`� 2. Quantity um ed:
1. Date of Pumping pate — Y p Gallons
3. Type of system: [] Cesspool(s) [4 epbc Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes [l No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of Sys m:
('2
6. System Pumped Byi
--
Name Vehicle License fVUmbe
Company
Location where contents were disposed:
S nature of Hauier / Date
Signature of Receiving facility Date
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