HomeMy WebLinkAboutSeptic Pumping Slip - 113 BRIDGES LANE 5/2/2016 Commonwealth of Massachusetts
C I Town of
y t rn Purnping Record NORTH ANDOVER
Form 4
DEP has provided this form for use by local Boards of Health. Other formJtM�(6eN6sedjA tr�h i
information must be substantially the same as that provided here. Before us^i llltNi'g,fbln`ri"fd oq�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
1. System p w
(owns on the _-'I
computer.use
only the �°r"
-,,..
to move tab key Add e °
cursor-do nat ,- _
use the return City/Town Stale Zip Code
key.
2. System Owner: ,W
w �� �� J
Name
Address(if different from location)
City/Town — Stale �. � Zip Code .. .--
Telephone Number
B. Pumping Record �
1. Date of Pumping bate 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ❑",optic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? [a)Y�9 ❑ No If yes, was it cleaned? Ej,.Yes ❑ No
5. Condition of System
:J� t
6. System Pure .gd B "
�ww
Name Vehicle License Number
Company
7. Location wherrptryt � fc:
J
my P
� r
_ --- d ��
,1.
Signature of Haul- --- _- - Date_ �..r�..��fM�9��,,r �-t -
Signature of Receiving Facility r
g 9 ility Date
15forrn4.doc-03106 System Pumping Record•Page i of 1