HomeMy WebLinkAboutSeptic Pumping Slip - 305 MIDDLETON ROAD 7/25/2016 Commonwealth of Massachusetts
City/Town of
System Pumping Record NORTH ANDOVER
Form 4
h
DEP has provided thi,5 forrn fbr use by local Ooards of Health. Other forms may be used, but the
information must be substantially the sarne as that provided here, Before using this form, check with your
locaf 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:
omen filling out 1. Systern Location:
forms on the
c6ratputer,use ++ .- ►�� t'1 _ S T _._.-._
only the fah key A41QreSS
t6 move YOUr
cursor-do Pol
use the return Cityrrov t� State _ _ zip Code - — -
key � 2. System Owner:
Name
Tddrtsa(if diH'erertt rr'om locaiipn) "" '- ^°-• ---- --,
State ---
�y Zip Code
efep one Number
B. Pumping Record
1. Rate of Pumping � �o__ 2. Quantity PUMped; —1 ---. _
Gallons
I Type of system: Z Cesspoof(s) K Septic Tank ❑ Tight Wank ❑ Grease Trap
❑ Other(describe): _..-
4, Effluent Tee Filter present? ❑ Yes No If yes, was it Gleaned? Yes ❑ Nc
5. Condition of System:
6. System Pumped yBy'.
Name
Veilitle License hlUmber er
1jinO..,
Company
7. Location where contents were disposed:
Signature of Hauler
S g F2tility Date
iSforma.doc-o3/o6
System Pumping Record-Page 1 of 1
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