HomeMy WebLinkAboutSeptic Pumping Slip - 500 GREAT POND ROAD 10/16/2017 RECEIVED
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,V14 OF NogrH At4DOVER
Commonwealth of Massachusetts 0jiLTH l EpARTMENT
Cityffown of
System Pumping Record NORTH ANDOVER
Form 4 i
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 Add" ss
to move your
cursor•do not ....�..'_,_.-. . ._!0\1
use the return City[Town State Zip Code
key.
2, System wrier: ,
Name
Address(id different from laca(ion)
Gity/Town — State
Zrp of
Telephone Number
B. Pumping Record
1. Date of Pumping " 4 - 2. Quantity Pumped: IrIn�bb
3, Type of system: ❑ Cesspool(s) ❑ Septic Tank Q Tight Tank ( Grease Trap
❑ Other(describe): _ . ._. „_..,., . ....___.._. .... , .._. .
4. Effluent Tee Filter present? ❑ Yes EA No If yes, was it cleaned? [J Yes ❑ No
5, Condition of Syste
6. System Pumped By:
Name Vehicle License Number
,Riad-- ve.r. �:: ron. ent-1
7. 127 O& Mt 110
._.. ._sTEwAR-rs SEPTIC; slrRvkCr
----_----..._.._._. .__ _,__, Bt 9D M.A 01835. ..,
Signature of Hauler Date. .. .._. _3_ ...�._..... ._.
978-372-7471
Signature of Receiving 1=acility pate -"
I5f0rm4,doc-03/06 System Pumping Record•Page t of f