HomeMy WebLinkAboutSeptic Pumping Slip - 325 BERRY STREET 4/25/2016 r
-C-\ 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, 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 i�11L
cursor-do not CitylTown - - - _ State Zip Code
use the return
key. 2 System Owner:
Name
Add-
LX ress(if different from location)
i
City/Town ate Zip Code
elep one Number
B. Pumping Record
- �-/ -- 2. Quantity Pumped:
1. Date of Pumping Datw Y P 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:
C
6. System Pumped By: ))
Name Vehicle License Number
Company
7. Location where contents were disposed:
- - ---- -- - I - --- - -- -- -- - --- -
I ch,-
Signature of Hauler Date
Signature of Receiving Facility Date
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