HomeMy WebLinkAboutSeptic Pumping Slip - 258 REA STREET 1/17/2017 RECE
ED
�u�etts IV
r ' Commonwealth ofa' Ku`
City/Town Of m m ° '
System ing Record TOWN OF NORTH ANDOVE
Form 4 HEAi H D1-[VJ`\'1 iilVE,N
DEP has provided this form for use by local Boards of Health.Cather 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 within 14 days from the pumping date in
accordance with 310 CMR 15.351.
Am Facility Information
Importaft When
Offing out fours 1. System Location:
on the ...––
use only the tab' J
key to move your
ti
cursor-do not
use threturn fi / ,,,,
key, cayfrown fState zip code
2. System per'
m.
Name
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Addreas(N dffieront from location) __._..
clty/Town ._. .Z ... .., -_
Siete Zip Code
Telephone Number
Be (Pumping Record
1, Date of PumpingDated 2. Quantity Pumped: . —
Cailona
3. Component: ❑ Cesspool(s) EKieptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter Present? ❑ Yes ❑ No If yes,was it cleaned? [] Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
x1y,
'gip Vehicle License Number
Company
7. Location where contents were disposed:
1,
Sigof Hayl`er Dat® 4-- — i
Signature of Reoelvi
ng Facility(or attach facility receipt) Datei"
tti M14.doc•11112
Syatem Pumping Record•page 1 of 1