HomeMy WebLinkAboutSeptic Pumping Slip - 496 WINTER STREET 7/21/2016 LN- Commonwealth of Massachusetts
Rim y City/-Fown of
System Pumping Record NORTH ANDOVER
Form 4
O] P has provided this form for use by Ibcai Boards of Health, Other forms may be used, but the
information must i)e substantially the same as that provided here. 8efore 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 lacaf Board of Health or other approving authority within 14 Mays frorn the pumping date in
accordance with 310 CM 15.351.
A. Facility Information
Important;
vvr:en flung out 1. System, Location:
forms on the
ComPuler,use
Only the tab key Address to move your
Corsof jo not
use the return City/Town Stake _ _ Zip Code — -
key.
2. Systern Owner:
Name
Address(If difterent from to❑a(ion} "_' -' ----'
CitylTown 1e _] de
et Zip Co
�°
ep ne Number
B. Pumping record
1. Date of Pumping Datt � ------ 2. Quantity Pumped: —
Gallons
3_ Typo of system: Cesspool(s) �,Septic Tank ❑ Tight-rank [] Grease Trap
Other(describe):
4 Effiuent Tee f=ilter present? ❑ Yes A§-,No If yes, was it cteened? ] Yes ❑ No
5. Condition of System:
6, System Pumped By:
_.
Name VghlOf4k License Nutn3]er
Company -
7. Location where contents were disposed.-
Haverhill VV V`I`� _...._._.... �_�_ ._..._
Sl5n—Rulf pr E r Puffe ,. . -- Date
Signature of R I _1 7
- Date
15Form4,pOC {73!68 System Pumping Record-page 1 of I
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