HomeMy WebLinkAboutSeptic Pumping Slip - 94 GRANVILLE LANE 4/29/2016 Commonwealth of Massachusetts
i 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 f114-1 �
computer.use _.[— l._...—V�v o/i2
only the tab key Address
to clove your m
cursor-do not
use the return City/Town State Zip Code
key. 2. System Owner:
Name
��° Address(it different from location)
fate Zip Code
el
City/Town
one Number
B. Pumping Record
1. Date of Pumping Date --- 2. Quantity Pumped: -f
Gallons
I Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 4 "o If yes, was it cleaned? ❑ Yes ❑ No
5. Condi'�tion of System:
61diy� --
6. System Pumped By:
Name p — Vehicle License Number
Company
7. Location wherete tgojs v ge s
ralford M 018
Signature of Hauler(973' 37. 2302 Date
Signature of Receiving Facility Date
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