HomeMy WebLinkAboutSeptic Pumping Slip - 292 GRANVILLE LANE 10/16/2017 IV F0
Commonwealth of Massachusetts
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City[Town of "J41A R
System Pumping Record NORTH ANDOVER
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:
forms on the
computer,use
J�
only the tab key Ad ress
V,use the return CilyfTown
-do not
to move your
cursor
key. 2. System state Zip Code
Owner:
Vf
Name
7�Tti�w)-'
-,�ddreis, f different from
'd FYf—To WW State Zip Code
etephone Number
B. Pumping Record
1. Date of Pumping -patwto-;V1 2. Quantity Pumped: Ga(tons�0.
3. Type of system: ED Cesspool(s) a4le-ptic Tank R Tight Tank Ej Grease Trap
❑ Other(describe): ...
4. Effluent Tee Filter present? "Yes n No If yes, was it cleaned? No
5. Condition of System:
6. System Pu pert By:
NaCe/_
V.;hicle License Nu
'&mp
Company-y..........
40 o
7. Location where contents were disposed: g7 S**OM5
Bra
37.4-2382
R Hauler Qtule �fiall Date
Signature of Receiving Facility
1510rm4.doc-03/06
System Pumping Record-page i of 1