HomeMy WebLinkAboutSeptic Pumping Slip - 248 REA STREET 10/16/2017 RECEIVED
Commonwealth of Massachusetts
City/Town of
HVER
System Pumping Record NORTH ANDOVEwH ENAOL "D(ERR T M E N T
0. KT'HPTA ANW
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,formsSy:sZteL ,cation:p,,,
fors on the ,
computer,use
only the tab key Address
to move yourA41111",
cursor-do not ' X/ -
use the return CilyfTown St/e Zip Code
key, 2. Sygre-m Owner:
Name
Address(if different
from
*j;C tion
6ty/Tow'n State zi coie
S�O
'Telephone i -' -Number
be Tr
B. Pumping Record
1, Date of Pumping 2
Quantity Pumped: A�-�- -
e �6aftns
3. Type of system: ED Cesspool(s) Septic Tank ❑ Tight Tank Grease Trap
r]L Other(describe): -- ----
4. Effluent Tee Filter present? Ej Yes No If yes, was it cleaned? 0 Yes L7 No
5. Condition of S em:
6. System Pu pe By:
Name A
vehicle License Number
-an y............
Comp
7. Location where c ntents were disposed:
Date
Ignature of Receiving-—Fac`ii`i-t—y --- -Da-t-e-
15(orM4,doc-03/06 System Pumping Record-page i or 1