HomeMy WebLinkAboutSeptic Pumping Slip - 138 LACY STREET 9/30/2016 Commonwealth of Massachusetts
City/Town of
System Pumping Record NORTH ANDOVER
Form 4
DER has prgvided this form for use by local Boards of Health. Other farms may be used, t}ut the
information must be substantially the same as that provided here. Before using this form, check with your
local 842rd of Health to determine the form they use.The system Dumping Record must be submitted to
the local Board of Health or other approving authority within 14 days frorn the pumping date in
accordance with 310 CMR 15.351,
A. Facility Information
Impoftant:
When ruing out 1 System Location:
forms on the
Computer.use
QNy the tab key A dr &5
�r
to move your
cursor-do riot
. _._.._1r. ire ._. ... .__....._ _... .... __... . ._ . ._ . ._.__„ .y _
use the return City Town 5t�te Zip coce
key. 2. S stern Owner:
Name
A41dress(if diffemrlt from location)
State Zip Cad — -
Telephone Number
S. Pumping Record
1, Elate of Pumping 1 2. Quantity Pumped: Gatlnr ns .._
3. Type of system: ❑ Cesspool($) ,Septic Tank ] Tight Tank Q Grease Trap
7 Other(describe):
4. Effluent -fee Filter present? Q Yes � No If Yes, was it ctearred? 0 Yes C1 No
5. Condition of Sy em'
B. System Pumped By:
1 � ,
Name vehtcle License Numl)er
Company
7. Location where contents were dispQSed:
HA 1'I 1
Slgrtature of FEauler -- -- - - -
$irta1u12 of ReCeivirg FBtility p7 '
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