HomeMy WebLinkAboutSeptic Pumping Slip - 275 ABBOTT STREET 9/25/2017Important: When
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Commonwealth of Massachusetts
City/Town of Oa i\ , (() ,i(? A
System Pumping Record
Form 4
SEP ;-:? 5 2011
TI OF NORTH ANDOVER
HEALTH DEPARTMENT
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 forrn, 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
1. System Location:
Addres
),(1_
Cityrown State Zip Code
2. System Owner:
()
Name
Address (If different from location)
Cityrrown
B. Pumping Record
1. Date of Pumping
State
Zip Code
Telephone Number
Date
2. Quantity Pumped:
)
' 22)
Gallons
3. Component: E1 Cesspool(s) 0-Septic Tank El Tight Tank 0 Grease Trap
0 Other (describe):
4. Effluent Tee Filter present? 0 Yes D No If yes, was it cleaned? 0 Yes 0 No
5. Observed condition of component pumped:
6. System Pumped By:
CY-4
Company
7. Location where contents were disposed:
Sig
of Hauler
Slgnatu of Receivl
(or
ch faclilty receipt)
Vehicle License Number
Date
Date
15forrn4.doc• 11/12
System Pumping Record • Page 1 of 1