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HomeMy WebLinkAboutSeptic Pumping Slip - 76 OLYMPIC LANE 10/20/2016 Commonwealth of Massachusetts RECEIVED City/Town of NOV 0 Mb System Pumping Record 'TOWN OF NORTH ANDOVER Form 4 JJEALTH DEPARTMENT DEP 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 Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information important: When filling out 1. System Location: forms on the computer,use YNA only the tab key Address to move your cursor-do not use the return dity/Town State Zip Code key. 2, System Owner: Name -Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping lo- .2o- 2. Quantity Pumped: -6—ate Gallons 3. Type of system: ❑ Cesspool(s) trseptic Tank Tight Tank © Other(describe): ------------------------ 4. Effluent Tee Filter present? ❑ Yes El No If yes, was it cleaned? Yes ❑ No 5. Condition of System- .................... 6. System Pumped By: 6 eo Na-me jM1 Vehicle License Number Company 7. Location where contents were disposed: ----------- Signature of Hauler Date t5form4.doc-06/03 System Pumping Record-Page 1 of 1