HomeMy WebLinkAboutSeptic Pumping Slip - 75 CROSSBOW LANE 10/16/2017 RECEIVED
Commonwealth of Massachusetts
City/Town of
TOWN OF NORTH ANDOVER
System Pumping Record NORTH ANDOVER HEALTH 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 Location:
- ition.
forms on the
computer,use
only the tab key Address
to move your
cursor-do not
use the return city A-W1-- State Zip Code
key. 2. System Owner:
Name
Address(if different from location)
Cityfrown State
C
,';
Ye` p
�-H?bn-n e Number
B. Pumping Record
1. Date of PumpingP
it
Q
2
-7 . Quantity Pumped;-4te Gallons
3. Type of system: Q Cesspool(s) -Irseptic Tank El Tight Tank 0 Grease Trap
[I Other(describe): ------
4. Effluent Tee Filter present? Q Yes �o If yes, was it cleaned? Q Yes L7 No
5. Condition of Syst
& System Pu
d By:
V I t.Alehlcle Lice se
N.2m.-;,r-
Company.._......_.._
0_Mp a—ny...... —.6-porter-st
W
7, Location where contents radf00, ! Ma 01,9,3
"� 44-2382 5
-Sf-q-n—aturegh- uler Date
-�,6Wa-K�r�'jf—Recj,�i-ng-FaciiJ-1y "- -D'a"i-e-
15(orm4.doc-03/06
System Pumping Record-Page 4 of I