HomeMy WebLinkAboutSeptic Pumping Slip - 740 FOREST STREET 6/10/2016 -C-\ Commonwealth of Massachusetts
City/Town of
System Pumping Record NORTH ANDOVER
Form 4
ti
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
computer,use
only the tab key Address
to move your
cursor-do not use the return City/Town State Zip Code
key.
2. System Owner:
Name
Address(if different from location)
CityfT-own S to Zip Code
�J
elep one Number
B. Pumping Record
1. Date of Pumping .2. Quantity Pumped: 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 ❑ No
5. Condition of System:
O
�y �
-------- .._ _.- -- -----..._ — -
6. System Pumped By:
jjName
� QQ Vehicle License Number
---
Company
7. Location where contents.where lsposed:
LC
Si -. - --- Date
nature y,Lj
Si ?, m
g 'cl F�eceiving Facility Date
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