HomeMy WebLinkAboutSeptic Pumping Slip - 65 BROOKVIEW DRIVE 9/25/2017Commonweajth of Mc,usefts
City/Town of
System Pumping Record
Form 4
v
SF P 25 21)17
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for use by local Boards of Health. Other forme may be used, but the
Information must be s ntially 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.
inposta*
'NV brms 1.
on the
taw onotte tab
kw to move yew
nOtiOr dO not •
Wormtdoc• 11/12
A. Facility information
Pumping Rico
1. Date of Pumping
3.
4. Effluent Tee Filter p
5. 0
8. System Pumped By:
7. Location when contents were dl
b()
2. Quantity Pumped:
Ganons
0Septic Tank J Tight Tank 0 Grease Trap
If yes, was it cleaned? 0 Yes 0 No