HomeMy WebLinkAboutSeptic Pumping Slip - 545 JOHNSON STREET 8/15/2017Commonwealth of Massachusetts lAORV PkIAD°\1
City/Town of 10140 EPPRVEI\11.
i..01.14A 0
System Pumping Record NORTH ANDOVER
Form 4
I::)f3 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:
Mien filling out
forms on the
computer. use
only lbe tab key AcJclre
10 move your
cursor - clo not
use the return
key
1Sforrn4.doo- 0/06
I. System Location--
-City
2. System Owner;
—i\LA y
Name
OY
Addrett (if different from (ocafton)
City/Town
B. Pumping Record
7
1. Date of Pumping
ziiicnTre
State Zip COde
Tafe-Ph
2. Quantity Pumped;
Gallons
3. Type of system: 17 Cesspool(s) Septic Tank El Tight Tank' LJ Grease Trap
LI Other (desoribe):
4. Effluent Tee Filter present
r6. Condition of
6, System P pe
Name
Company
7. Location whe
Signature o
Yes 0 No If yes, was it cleaned? AYes D No
disposed:
Vehicle License Numeer
2 -
Date
'
Signature of Receiving Facil_ity Date
System Pumping Record - Page t or