HomeMy WebLinkAboutSeptic Pumping Slip - 151 SANDRA LANE 9/25/2017Commonwealth of Nl usetts
City/Town of j y,h m
System Pumping Record
Form 4
v
N OF NQRTN ANDOtVER
l#EAL1TH DEPARTMENT
DEP has provided this loan 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 you
local Board of Health to determine the form they use. The System Pumping Record must be submitted ti
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
System Location:
a
Address
//7. r ..c -Ata—N
City/Town
2. System Owner.
(
Name
Address (i different from location)
CIty/Town
state
Zip Code
Zip Code
Pumping Record Telephone Number
1. Date of Pumping L . , "6C._�.�
Date 2. Quantity Pumped: Gaiions
3. Component: ❑ Cesspool(s) ❑Septic Tank ❑ Tight Tank
9 0 Grease Trap
0 Other (describe):
4. Effluent Tee Filter present? 0 Yes ❑ No If yes, was it cleaned? 0 Yes 0 No
5. Observed condition of component pumped:
r. Location where contents were disposed:
Vehicle Uosnse Number
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