HomeMy WebLinkAboutSeptic Pumping Slip - 695 MASSACHUSETTS AVENUE 3/15/2011 �, Commonwealth of Massachusetts
City/Town of &"N �� � U I I
-_ Pumping r �1 ���tl ANDOVER stem Record NORTH ANDOVER DEPARTMENT
HEAL1
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
Important:
When filling out 1. System Location:
forms on the ,ra
computer,use
only the tab key Address / —m
to move your
cursor-do not -. State Zip Cade
use the return CitylTown
key. 2. System Owner:
Name
�^ Address(if dif#stent from Cocatian)
City/Town
__.. State Zip Code
,
Telephone Number
B. Pumping Record
2. Quantity Pum ed
1. Date of Pumping
Gallons ionsD --
3. Type of system: ❑ Cesspool(s) Tank ❑ Tight Tank ❑ Grease Trap
L] Other(describe): _._.—....._._.. _ _. .
4. Effluent Tee Filter present? ❑ Yes ❑ No if yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Name
— — Vehicle License Number
Company
7. Location where contents were disposed:
Signature of Hauler Date
Signature of Receiving Facility Date
15form4.doc"03106 System Pumping Record•Page 1 of 1
TO WN 0 F N 0 R"I'll A N D 0 V E F�
SYSTEM PUMPING RECORD
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N ) s''FFNI OWNER & ADDRESS SYSTEM LOCr\Tl(")N
(narn pie: left font � of hous� )
u,\T L, 0h PUMPING QUANTI'T'Y P U M 1)ED Ne-)
S 1)0 0 1-: N0 YES SEPTIC TANK: N0 Y L,S
TU R LI/ EMERGENCY
OF SERVICE: ROUTINE
[�'R VA Tl 0 NS:
GOOD CONDITION J, FULL TO COVIlk
H PA V Y GREASE B A FFL L,,S IN 1)1-A CE
ROOTS L F, A C Ff Fl EL D f Z U N B A CK
EXCESSIVE SOLIDS FL 0 0 D E.D
SOLIDS CARRYOVER OS H E R (E X Pl�A I N)
FL
TRANS'FERRED TO: