HomeMy WebLinkAboutSeptic Pumping Slip - 790 FOREST STREET 5/2/2016 Commonwealth of Massachusetts
(amity/Town of
System Pumping Record NORTH ANDOVER,_,
Form 4
7� „ Pt J4
` fit Il
DEP has provided this form for use by local Boards of Health. Other forms m ' r�t Utse'd
information must be substantially the same as that provided here. Before using (h�s�Porttr„ iG 'P your
local Board of Health to determine the form they use. The System Pumping Record must be stimltted 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 y, Location:
1. sfem
forms an(he e 7 ter,(,
computer use
only the tab key Addres r,
to move your ' 1 \. �� /`� �✓fir� /� �� � � ®”,,._
cursor-do not
use the return City/Iown Stale Zip Code
key.
y� 2. System Owner:
Name ---
lf�-A Address(if different from location)
CitylTOwn State �. Zip Code "
Telephone Number
B. Pumping ReGorc! _ ---
1. Date of Pumping byae� 2. Quantity Pumped: Gallons
3. Type of system. ❑ Cesspool(s) ®Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? W."Ye ❑ No If yes, was it cleaned? 7� (es ❑ No
5. Condition of System:
6, System Pu:pp,g-0 y:
w
Name Vehicle License Number
Company
7. Location where contents were disposed:
Signature of Nauter Date
signature of Receiving Facility Date
15(om4.doc-03106 1"Wich 9 wrr Pumping Record•Page t of t