HomeMy WebLinkAboutSeptic Pumping Slip - 97 LOST POND LANE 8/4/2016 4 Z\ Commonwealth of Mar> achusetts
City/Town of
System Pumping Record NORTH ANDOVER
Form 4
d1=11 has provided this form for use by local Boards of Health. Other forms may bc, used, nut the
information must be substantially the same as that provided here. Before using this forrn, check vviih your
local board of Health to determine the Corm 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 tnforlmati;n
tmpormnt:
When frlling out 1, System Location:
forms arl the
oompuler,use �f
._-_
only the tab key Ap4ress _
to move your
cursor-do not
use the return Gityrrown State Zip Code
Key. 2. Syst�rn Owner:
VkA
Name
Y—
G° Address(if different from loceiion) ----•
eie one l,tumher
B. Pumping }record f
i. rite of Pumping1- - 2. Quantity Pumped: � ....�......
Gallons
3, Type of system: ❑ Cesspooi(s) Septic Tank CI Tight Tank Grease Wrap
❑ Other(describe): •.
4. Effluent Tee Filter present-? Yes ❑ No If yes, was it cleaned? Yes ❑ No
5. Condition of System,
6. System Purnped sy:
N _. �. . -- „ .- - � -- ...
Vehicle License NUrt}bEI
Company -
7. Location where contents were disposed,
40 S Porter.Signature �...- —
Date
'7 021a
t trd, Ma 018S__ �.
g �/ F2382 _�. -- -
!tl flan
Ibform4.aaG-�9ros
Systern Pumping R¢cord-Pjye 1 of 1
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