HomeMy WebLinkAboutSeptic Pumping Slip - 1773 SALEM STREET 4/11/2017 � tv
, Commonwealth of Massachusetts
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City/Town o E `r 6 iv0
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System Pumping Record NORTH ANDOVER
Form 4
k .
05P has provident this form for usa by local Boards of Health. Other forms may be used, but the
information must be substantially the sante 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 1.4 days from the pumping date(n
accordance with 310 CMR 15.351.
A. Facility Information
Important;
When tiling out 1. System Location:
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computer,use _ _...
only the fab key f
to move yourcur '._. 4'"1 _ ~._ _.. + . ., . _ _ �t -
use the
- et not City/Town State zip Code
use Ehe return
kay. 2. Syste ,wpee_r:
Name
Address(if different from location)
CitylTown State ziP e
Telephone Nurnber
B. Pumping Record f
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1. pate of Pumping 2Date . Quanti#y Pumped: -tan ....
llons
3. Type of system: Q Cesspool($) 64 Septic Tank ❑ Tight Tank Q Grease Trap
[3 Other(describe): -- — - _._ _.. ..____.._. _... . __. ...._..._-•__-•- --•_-._ . __
4. Effluent Tee Filter present? Yes No if yes, was it Cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped Sy:
Name Vehicle License Number
Company
7. Location where contents were disposed'
Signature of Hauler Rater
— ate
Signature of Receiving Facithy - .
Date —
16form4.doa 03106 System Pwmptnq Rarorp-P$gs I of