HomeMy WebLinkAboutSeptic Pumping Slip - 785 TURNPIKE STREET 5/2/2016 Commonwealth of Mass ChU ett
City/Town of
System Pumping Record NORTH ANDOVER
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may llr�.f it the
information must be substantially the same as that provided here. Before using th y r��AlwfY-thly,�a r
local Board of Health to determine the form they use. The System Pumping Record must be� tcf 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 —
1m;zortant: _ _ _
When filling out 1, System oc
forms on the
"� ra,it�n
computer,use
only the tab ke y L Add rPSAM
to move your I <
01OU f.L. .. __ .. ._ --... _. _... _.-.._._ 0 015
cursor-do not Cit frown fate - Zip Code
use the return y
key. 2. System Owner:
4 (�
� 7
Name
° Address(if different from location)
CityfTown State Zip Code
Telephone Number
B. Pumping Record
--- — - ---
1. Date of Pumping -_...-_----_._. -_.—_.—_- 2. Quantity Pumped: -
Date Gallons
3, Type of system: ❑ Cesspool(s) E'`Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter,present? ❑ Yes 0 �No If yep was;lt cleaned? ❑ YQs �
, ''No
w y w ,
5. Condition of System: �,.,1 r � „ 4 n,
6. S tem Pum ed
r?, 171(.u rh
Name Vehicle LicensehY�rh 'eW --
q
9 y() rya
Companyyr. (,�sti.
7. Location Nhere contents were di ased:
J i .✓� d � `,"
Sin re ofNaul
�1
g er ' Date -
1
Siy a ure of Receiving Facility Date
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