HomeMy WebLinkAboutSeptic Pumping Slip - 66 SUNSET ROCK ROAD 9/1/2016 Commonwealth of Massachusetts
City/Town of
System Pumping Record NORTH ANDOVER
Form 4
DEP has provided this form for use by lootii Boards of Health. Other farms may be;used, Out the
information must be substantially the same as that provided hero. Before using this form, check wiih your
local Board of Health to determine the form they use. The System Pumping Record must be submr tted 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 filling cut 1. System Location:
th
tor alt e
mp
COrnUIBr.use
only the tab key Appr 5 _
t6 move your
cursor-do not -• - ,
use the return CitylTown stale Zip CocTe
key.
2. S em Owner; �a
VL-
G1tJ�'
Name
Address(if diftrent from locatian)
CIty11 own State Zip Code
Telephone i�iumlYer
B. Pumping Record � -
1. date of Bumping Cate 2. Quantity Purrtped: Gallons
3. Type of system, ❑ Cesspool(s) eptic Tank 0 Tight Tank ❑ Grease Trap
❑ Other(describe);
4, Fffluent Tee Filter present? ❑ Yes 04--yQ If yes, was it cleaned? ❑ Yes
5- Co stem:
Haverhill WWTP
Wind Rivor Bradford, Ma 0133
163 Western Ave ?. _
�i�i7��>"iw All1 4_ chicle ucen5e � .,.. �_.... .__.
Gornpany
7. Location where contents were disposed:
Signature of Hauler date
154armd.�¢c•93106 System Pumping Record-Pigs I of 1