HomeMy WebLinkAboutSeptic Pumping Slip - 54 TUCKER FARM ROAD 7/19/2016 F
Commonwealth of Massachusetts
City/Town of
System Pumping Record NORTH ANDOVER
.y
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, check wish 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 Location: _ \(
forms on the tJ e-, ,ems m
computer,use
only the tab key Address your
co move edo not
Z
State y i
use the return Cit own Code
key. 2. System Owner:
Name
Address(if different from location)
City/TOwn Sat Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Geuons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): _.. .__
4. Effluent Tee Filter present? ❑ Yes (2� No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Name Vehicle License Number
Company
7. Location where contents were disposed:
ich,
—— ----–-- _ _.. ---- - - - ---
-Date--
Date----
Signature of Nauler
Signature of Receiving Facility Date
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