HomeMy WebLinkAboutSeptic Pumping Slip - 163 CANDLESTICK ROAD 10/16/2017 RECEIVED
Commonwealth of Massachusetts ; `i7017
City/Town of T ANDOVER
DOD
System Pumping Record NORTH ANDOVER HEAUVH DEPARTMENT
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 L,ocation:
forms on the (/a
computer,use
only the tab key Address _ � .-
c move your / 4` "S-! ... .. _... ..,....._ cp/
cursor.do not •_•_'►'••"_.•! ____ •�,�
use the return Cityfrown State - Zip Code u
key.
2. Sytm Owner:
Name
Address(if different from tocation3
Cltyfrown State
Zip Code r
Telepttane Number
B. Pumping Record
1. Date of Pumping 65 te�—`5 2. Quantity Pumped: -• __... __. ..
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes❑'No If yes, was it cleaned? J Yes [] No
5. Condition of Sys :
0. System P ed
E_/ % ......._ ._...._ __.
Name Vehicleeense Number
_
Company . ._...._ l
ere�'� �s dia�p
7. Location where
Signalure f, au- _ _. ._. naatete
i
Signature of Receiving Facility Date
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