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HomeMy WebLinkAboutSeptic Pumping Slip - 555 BOSTON STREET 6/15/2016 J fi Jf I Z f Commonwealth of Massaohu ' etts City/Town of Merrimac � System Pumoing Record , : r tt�i,d tri ut��r.�it Form Tan",o. 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 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important:When filling out forms 1. System Location: - an the computer, „�-°� �� �„ use only the tab - .�3) r°' 6 r�of cursoormdo not your Address YY V/ Y Y ✓� use the return _ rte°��C ' MA Code key. City/Tawn ". — State Zip —. 2. System Owner: Name V fff renm Address(if different from location) City/Town State Zip Code Telephone Number B. Plumping Record 1. Date of Pumping D 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(§) A3n Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition off `stem: 6-6 6. System Pumped By: �/(. Name Vehicle License Number BORACZEK'S SEPTIC & DRAIN Company 7. Location where contents were disposed: Signature of Hauler hate Signature of Receiving Facility Date t5form4,doc-03/06 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts 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 be used. but the information must be substantially the same as that provided here. Before using this form,cheek 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 drays from the pumping date in accordance with 310 GMR 15.351, A. Facility information Important: When tilling out 1. System Location: forms on the computer,use only the tab key Address to move your n �.--�-- ... cursor-do not -= cu Cit own .... .... State Zip bode use the return y key. 2. System owner, Name Address(it different from location) City/[avm Slat Zip Code _ Tat hone Number P _. B. Pumping Reeord 1. Date of Pumping �.r•.r.� /� 2. Quantity Pumped; Date Gallons 3. Type of system: [] Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): _. _. _.. .. ._..._ �,.. ..... . u. . 4. Bffluent Tee Filter present? ❑ Yes ❑ No if yes, was it cleaned? ❑ Yes © No 5. Condition of System: 6, System Pumped Sy: Name — Vehicle License Number Company 7. Location where contents were disposed: Signature of Hauler �• --.. Date. .._._... Signature of Receiving Facility Date t5forrrA.doc•03106 System Pumping Record•Page I or 1