HomeMy WebLinkAboutSeptic Pumping Slip - 193 LACY STREET 3/30/2011 Commonwealth of Massachusetts
City/Town of
- System 'nRecord NORTH ANDOVER
- Form
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 day�frorn the purrpl PIA' �� o;
accordance with 310 CR 15.351. trd �r. �
M
A. Facility Information —
Important: � t iwt^I s Ap h,C)t�� d t AW�(rot t
When filling out 1. System Location: Lit 9 d IDk,,,PA I LtP�.I N"4
forms on the /
computer,use _.../ d .L✓° - �J- '
only the tob key Address y ""
to move your ✓; y Cfti1 ~
cursor-do not City/Town fate Zip Code
use the return
key. 2. System Owner:
V Cj
Name —
—__..--- -—--_
Address(if different from location)
State Zip Code
City/Town j
Telephone Number _
B. Pumping Record ....
1. Date of Pumping -p 2. Quantity Pumped: Gallons
3. Type of system: El Cesspool(s) Septic Tank El Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? W. Yes ❑ No If yes, was it cleaned? es ❑ No
5. Condition of System:
y
6. System P umped By:
Name License Number
Company
7 Location where contents were disposed: `
------._ . ---
Signature of Hauler Date
_._--F- ----_.
_.____, __-_..___— Date
Signature of Receiving Facility
System Pumpi Record•Page 1 of 1
t5form4.doc•(73/06