HomeMy WebLinkAboutSeptic Pumping Slip - 34 BOXFORD STREET 10/16/2017 RECEIVED
Comm' onwealth of Massachusetts
City/Town of -rOWN OF t4ORTH ANDOW-R
H 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 Locatio
forms on the
computer,use
only the lab key Addres
to move your r /—N
cursor-do not — . — -- — /I J/
City o n
State zip COX
use the return Ci §6 e
key. 2. Sys Ife-1 Owner:
e
Address(if different from location)
Cityffown state
Telephone umber
B. Pumping Record
R-Y
1. Date of Pumping Date2. Quantity Pumped:
3. Type of system: ED Cesspool(s) ie-'2Septic Tank [:1 Tight Tank ❑ Grease Trap
[I Other(describe): ...
4. Effluent Tee Filter present? FI Yes No If yes, was it cleaned? ❑ Yes Q No
5. Condition of SystE)W-
6. System q ped Ay:
Name Vehicle License Number
Company
7. Location where c; n disposed:
','WWy,
I re
f n'at re'o aul, ...........
er Date
ng-F
-gi4r�aT�,e Receiving
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