HomeMy WebLinkAboutSeptic Pumping Slip - 65 SPRING HILL ROAD 1/30/2017important:
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Ky.
t5form4.doo. 03/06
Commonwealth of Massachusetts
City/Town of
System Pumping Record NORTH ANDOVER
Form 4
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 within 14 days from the pumping date In
accordance with 310 CMR 15.351.
A. Facility information
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1. Syst Locatio
'ACT'
ty
2. Sysre 0 ner:
ar.t
--1-e-e=
IL
AddretS (4-different from location) --
B. Pumping Record
1. Date of Pumping ''2, Quantity Pumped:
Date
State
4 44M4 00.
00
lions
3. Type of system: Cesspool(s) %Septic Tank U Tight Tank D Grease Trap
LJ Other (deS0ribe):
4. Effluent Tee Filter present? Cj
5. Condition of System:
6. Systst4"lumped
•Name tflVIronment
0011;este4MA 01930
7. Location where contents were dispOSed:
Company
ture of Hauler
Signature of Receiving Facility
lf yes, was ft cleaned? Ej Yes CD No
Vehicle License Number
tlaverh,41"i
Bra- or, orc, 0t
Date
System Pumping Record • Page 1 of 1