HomeMy WebLinkAboutSeptic Pumping Slip - 151 OLYMPIC LANE 7/19/2016 -C-\ Commonwealth of Massachusetts
City/Town of
System Pumping Record NORTH ANDOVER
S 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 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 Location:
forms on the c
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, r
computer,use � `__N\1.'M�t�._._L�_
only the tab key Address
to move your K ,^\ M
cursor-do not — — I_�_n_ \�e .. .._ --
use the return City[Town State Zip Code
key.
2 System Owner.
Name
Address(if different from location)
y
St to Zip Code
Cit !Town
Telephone Number
B. Pumping Record 1
1. Date of Pumping -- 2. Quantity Pumped: 4 -
Date Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): __ . .._. - -- - _ . _. ..-.._...-..- -
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes G1 No
5. Condition of S m:
6. System Pump d By:
Name Vehicle License Number
Company
7. Location where contents were disposed:
Signature of Hauler Date p y
Signature of Receiving Facility Date
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