HomeMy WebLinkAboutSeptic Pumping Slip - 315 BERRY STREET 5/18/2016 Commonwealth of Massachusetts
(amity/Town o "
< ❑T
❑ System pin g Record NORTH
ANDOVER
❑❑�❑ Farm 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 nol
use the return
Cit wn Zip Code
State
key. 2. System Own r. j
Ik Name
Address(if different from location)
City/Town State r Zip Code
Telephone Number
B. Pumping Retord —
I
1. Date of Pumping _...-_----__...- ._.._.—._--- 2. Quantity Pumped: Gallon
Date
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes a If yes, was it cleaned? [❑ Yes o
5. Condition of System:
Y ...
6. System Pumped Bppi T
Name / Vehicle License Number
l/
Company
7. Location where contents were disposed:
Signature of Haulers w " l(p "1 �{'� , at
Signature of Receiving Facility t {!I ti Date
15form4.doc.03/06 System Purnping Record•Page 1 of 1