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HomeMy WebLinkAboutSeptic Pumping Slip - 351 WILLOW STREET 5/30/2017 (3) Commonwealth of Massachusetts City/Town of North Andover System Pumping Record 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 usin is form, check with your local Board of Health to determine the form they use. The System Pumpin rd must be submitted to the local Board of Health or other approving authority within 14 days fr pu "ly�g date in accordance with 310 CMR 15.351. �` A, Facility Information filling When g out formsI. System Location; on the computer, use only the tab ❑ 1 ° ...._4 ....... key to move your Ad 0ress cursor-do not North Andover use the return - - key. City/Town State Zip Code VQ 2. System Owner: I ❑. ., ...... .. .............--- --- Name -- _... rr,�R ---- -- - Address(if different from location) ......... ..------ - --- CityFfown State Zip Code Telephone Number ----------------- B. Pumping Record 1. ©ate of Pumping 2. Quantity Pumped: W x ------ Date Gallons 3. Component: ❑ Cesspool(s), ❑ Septic Tan ElTight Tank ElGrease Trap .... . . C .* Other(describe): ---- µ❑ 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed jondition of component pumped: System Pumped By; i' - - ......----- _ ...... _ me _ '� Vehicle license Number _ art Septic 58 So Kimball St Bradford Ma ... v — - __...... Cman 7. ocati where contents were disposed: ' 0 so - III st bradford ma I Si nature of Hauler Date ^'."' Sign ture of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Purnping Record•Page 1 of 1