HomeMy WebLinkAboutSeptic Pumping Slip - 111 BROOKVIEW DRIVE 10/16/2017 RECEIVED
Commonwealth of Massachusetts
City/Town of �r) flej U:NMI]I AN[)OVU`11,'�
System Pumping Record NORTH ANDOVER L:rDu1WHOLKI
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 -Pg. X-V 1...'-o-v
computer,use [J C..131
only the tab key55
cursor-do not
to move your 1z'_411 4 .)
use the return City[Town
State Zip Code
key. 21 4zgste Owner:
Name
Address(If differont from location)
CityfTawn State Zip Code
eI hon
B. Pumping Record
1. Date of Pumping
Date 2, Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool($) Oes"elptic Tank El Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? Ej Yes &?"No If yes, was it cleaned? ❑ Yes P_Ko
5. Condition of System,
6. Sy_stem Pumped By:
sor
Vehicle License Number
Company
7. Location where contents were disposed:
Signature of Hauler ........---------- W .
Pswich At-
Signature.of Receiving Fac7itY Date.. . .._.._
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