HomeMy WebLinkAboutSeptic Pumping Slip - 638 FOREST STREET 5/4/2016 Y
f
-C-\ Commonwealth of Massachusetts
City/Town of
System Pumping ecord 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
cursor do not ---�-._� V.__
use the return City/Town late Zip Code
key. 2. System Owner:
--
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping - � --� 2. Quantity Pumped: --� --
Date Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): --
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of Syste
6. System Pumped By:
------- �a' -- _ - -- - IS-�Name —Vehicle Lice-�-n NumU ber
Company
7. Location where contents were s se�i � O .�� r
'F :, pj
a �088 S 0 R.1 4 i X4,31
z l r r e
Signature of Hauler , ,�U �-- Date
•
-- --- ---- ------- - - — - ---
Signature of Receiving Facility Date
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