HomeMy WebLinkAboutSeptic Pumping Slip - 165 BOSTON STREET 10/16/2017 RECEIVED
OM' 16 ?017
'LN Commonwealth of Massachusetts TOWN OF NORTH ANDOVER
City/Town of HEALTH DEPARTMENT
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 ruing out 1. System Location:
forms on the
computer,use
only the tab key Address
to move your
cursor-do not
use the return City/Town �la'I e Zip Code
key. 2. System Owner:
Name
Address(if-different from location)
d ity/Tow n St..ate
Zip Co
Telephone Number
B. Pumping Record
1. Date of Pumping 7
Date 2, Quantity Pumped:
Gallons
I Type of system: Ej Cesspool(s) OKS El eptic Tank Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? E] Yes t No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System-
6. System Pumped By:
Name Vehicle
"�O_MP;_y....... ------
7. Location where contents were disposed:
Signature of Mauler �" Date
Grp
Signature of Facility 7cb Date
5
t5form4,doc-03/06
System Pumping Record-Page i of I