HomeMy WebLinkAboutSeptic Pumping Slip - 83 ACADEMY ROAD 10/16/2017 RECEIVED
Commonwealth of M ssac usetts 1000Fj
City/Town of
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 fillingt out 1. System oc)tkinoe
forms on the
computer,use V
only the tab key AdtlreSs /t _ - •• -
to move your
cursor.do not �. ._..,.__.... . ��--- _. ._._... _
use the return CityFrown Scale
Zip Code
key.
2. Syste Ow e
Nam -
Address(if different from location) — - -- ---•-
City/f'o+vn State "&Oaa.
rf�C1 �3
79"
...,.._.. ._.... .... .... .._
Telepe Number__._� ..
B. Pumping Record//
1. Date of Pumping --i - ,.._1 2. Quantity Pumped:
Date p Gallons
3. Type of system: Cesspool(s) ❑ Septic Tank Q Tight Tank Q Grease Trap
Q Other(describe): _, . ,-. _ _.., ___.._. «... . ,..
4, Effluent Tee Filter present? ❑ Yes WeNo If yes, was it cleaned? ❑ Yes Q No
5. Condition of Sys
6. System Pu ed By f
vehicile License Num.,...,.__ber_........
_........_ ._..._ .._.
Compal `
t' /'�
7. Locatotn ercoFttkk'(It /fl disposed:
-era
t 3 Q
Signature of a
Date
Signature of Receiving Facility Date
tSform4•doc-03/06
System Pumping Record.Page 1 of 1