HomeMy WebLinkAboutSeptic Pumping Slip - 89 WINDSOR LANE 6/3/2016 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 fining out 1. System Location:
forms on the °. �,� l•�/r
computer,use _._ _ ._ .�. - --------' -
only the tab key Add,�ss/ �y ,r /
to move your 1� \-- .Sc Y _... _......_. /L'_,
cursor-do not CitylTown State Zip Code
use the return
key. 2 System Qwner:
" --- - - _Wit.-- ._ -_�N(
Name
Address(if different from location)
Cityrrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping --- 2. Quantity Pumped: — ---
Date Gas
3. Type of system. ❑ Cesspool(s) ptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes M,,N/o If yes, was it cleaned? ❑ Yes Elmo/
5. Condition of System:
6. System Pumped By:
Name /J Vehicle License Number
-- ---..........-
Company
7. Location where c��` � VVWepp
rdford .1_
Signature _ moo
Hauler( 7 7'4® Date --� -- - -- -
-..--------------------- --__-------------- - ----._ - ._-._.---...._..------...-----
Signature of Receiving Facility Date
15form4.doc•03/06 System Pumping Record-Page t of 1
