HomeMy WebLinkAboutSeptic Pumping Slip - 650 FOREST STREET 5/10/2016 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 ruing out 1. System Location:
forms on the //• - frQ� i
s
computer,use J_� 1--.... �
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 locatio-- 'nn))
CitylTown 51ate Zip Code
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Telep"hone Number
B. Pumping Record
1. Date of Pumping 2.— 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:
6. System Pumped By:
Name Vehicle License Number
Company
7. Location where contents were disposed:
-- --- .-- ----
Signature of Hau s Date
Signature of Receiving Facility Date
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