HomeMy WebLinkAboutSeptic Pumping Slip - 1116 GREAT POND ROAD 7/5/2016 Commonwealth of Massachusetts
City/Town of
System Pumping Record NORTH ANDOVER
Form 4
Dine has provided this farm 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 Titling out 1. System Location:
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R. Pumping Record
I, Date of Pumping � � 2. quantity Pumped: ...
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3. Type of system: ❑ Cesspool(s) $1.15eptic Tank ❑ Tight Tank d Grease Trap
ID Other(describe); .--
4. Effluent Tee Filter present? Yes K~No If yes, was it ciaaned? 0 Yes ,❑ No
5. Condition of Sy tem:
5. System Pumped By,
2me J� Vehicle License NumpeY
Company
7. Location where contents v+WaWWR WWTP Haverhill W.VV-fP
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