HomeMy WebLinkAboutSeptic Pumping Slip - 2050 SALEM STREET r,
Commonwealth of Massachusetts
— � City/Town of � ,
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Systellin Purroping Record NORTH ANDOVER r
Form 4
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DEP has provided this form for use b local Boards of Health, Other forms ma ebb t4P ) �?k(i1daVE-�
information must be substantially the same as that provided here_ Before using this form, j,46kAWith 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
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Important:
When filling out
1. y Stem
Location,
forms on the 't_
L
�n7p use
only the tab key Address � ', '5 ._
to move your ���� � �.... "
cursor-do not City/Town Slate Zip Code
use the return
key, 2. System CO
Uvlko
Name
— Address(if different frorr)location)
City/Town State Zip Code "
Telephone Number
B. Pumping Record
1, Date of Pumping ate � ._.—___
- 2. Quantity Pumped: Gallons --
3. Type of system: ❑ Cesspool(s) [Lj" eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): --. .__ . -_
4. Effluent Tee Filter present? ❑ Yes fo If yes, was it cleaned? ❑ Yes ❑„,.No
5. Condition of System.
6. System Pumped By:
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Name Vehicle License -
--
�
Company
7. Location whirr contents were disposed:
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� ,gym �� l �� ti� ,
Signature oft{ �Y f
_-, __. .
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g
5i nature of Rece -- ---
wing acilily_ """T �"
�5forn)4,doc•03/06 System Pumping Record•Page 1 of 1