HomeMy WebLinkAboutSeptic Pumping Slip - 169 JOHNNY CAKE STREET 10/16/2017 RECEIVED
Commonwealth of Massachusetts oc I
City/Town of
()V-t4ORTH ptg)OVER
System Pumping Record NORTH ANDOVER HEALTi-i DEPARTMENT
Form 4
DEP has provided this form for use by local Boards of Flealth. 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
.__)_.C)�
only the tab key Ad eq
to move your
cursor
-do not Jc�� It's—
use the return CityfTown Zip Code
key- 2. Syst Owner:
S S
Name
Address(if different from location)
CItylTown stats'_ Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
ate Gallons
3. Type of system: 0 Cesspool(s) E43eptic Tank Q Tight Tank 0 Grease Trap
Other(describe):
4. Effluent Tee Filter present? Q Yes No If yes, was it cleaned? [I Yes 0 No
5. Condition of System:
6. System Pumped By:
Nam vehicle_License Number
Company
7. Location where contents were disposed:
iioivernoi wWTP
-�ignature
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