HomeMy WebLinkAboutSeptic Pumping Slip - 138 LACY STREET 10/16/2017 RECEIVED
Commonwealth of Massachusetts ()('11'r 11 (3 2017 R
TOWN OF NORTH ANDOW
City/Town of KEAj.TH 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 filling out 1. System Location:
forms on the
Computer.use
only the tab key Address
Io move your er
Y)
cursor-do not
use the return City[Town Slate Zip Code
key. 2. System Owner:
j4Trre--"
Address(it different from location)
ityrrown State Z' ,Cod
Telephone Number
B. Pumping Record
1. Date of Pumping oate 2. Quantity Pumped: Gaaon
3. Type of system: ❑ Cesspool(s) Septic Tank E] Tight Tank El Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? Yes No
5. Condition of System:
6. System Pumped By:
Name Vehicle�License Number........
'Company----------- �-Iavernjji vvvv-fp
7. Location where contents were disposed:
SIOdfibrid'"A'
-a49 7 ) 374-;2
Ma 01835
7— ... ......
` -83ff2
ignature
of Receiving
1510(M4.doc.03106 System Pumping Record-Page I of 1