HomeMy WebLinkAboutSeptic Pumping Slip - 58 PHEASANT BROOK ROAD 9/12/2016 Commonwealth of Massachusetts
City/Town of
System Pumping Record NORTH ANDOVER
Form 4
a1=P has provided this form 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 Purnping Record must be submitted to
the local Beard of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
lrn�OdS3ttt:
When flung oui 1. System Location:
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use the return Cdyi7own Slate Zip Cod-
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2— System Owner:.. ..�.
Name
i°•^
Address(if dlfterent from location)
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to Zip Code "
Telephone Nijmljer
B. Pumping Record
1. Mate of Pumping WWI — ---- 2. Quantity Pumped:
Date C��Ilgng
3. Type of system: ❑ cesspool(s) ( Septic Tank Q Tight Wank ❑ Grease Trap
a Other(describe):
4. Effluent Tee Filter present? 2KYes ❑ No If yes, was it czeened? fgryes ❑ No
5. Condition of System:
0. System Pumped By: Windv
er$AYl1"01 Men
1<I 1 r [; .
� . Y _W"feM.Am
Name vehtcle License Nurrmbr!r
Company
7. Location where contents were disF469rhill WWTP
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g 97$ 374- J G
Signature pf{ a4eiving FseiGly Bate
t5formd.doe•bolos Sy3t016n Pumping Record-Pagg ¢ of i