HomeMy WebLinkAboutSeptic Pumping Slip - 352 FOSTER STREET 5/18/2016 r Commonwealth of Massachusetts
�
-_ City/Town of
System Purriping Record NORTH ANDOVER
t � 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:
��mp� the
use
stem Location:
c� - �_"'✓�_-c..?__._ . __._._ ._..._-- ._ . .._ _ .. .._
When fillip out ' System
_ -- --
only the tab key Address
to r7ove your Cit lT� State 6 !J A
cursor-do not
----
use the return y Zip Code
key. 2. System Owner:
po
a e
Address(if different from location)
City Town State lip Code
Telephone Number
B. Pumping +d���r _ — --- --- --
1. Date of Pumping -- -:_.� ° ./_--.—.__._ 2. Quantity Pumped: _._❑ - _
Date Gallons
3. Type of system,: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ YesNo If yes, was it cleaned? ❑ Yes ❑No
5. Condition of System:
6, System Pumped By:
Name ��77 Vehicle License Number
Company
7. Location where contents were disposed:
Signature of Hauler Date Ipswich, MA.
..........
Signalure of Receiving Facility Date
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