HomeMy WebLinkAboutSeptic Pumping Slip - 543 BOSTON STREET 10/16/2017 RECEIVED
Commonwealth of Massachusetts (JUI 16' 2017
• City/Town of TOWN OF NORTH ANDOVER
System Pumping Record NORTH ANDOVER HEALTH DEPARTMENT
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
to move your
cursor-do not
use the return
State Zip Code
key- 2 Syste i Owner:
Name
Address(if different from location)
Cityfrown Stale
Telephone Number
B. Pumping Record
1. Date of Pumping Date Cluantity Pumped:
Gallons
A'
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank F] Grease Trap
[] Other(describe): .... —
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of S em:
Condition
ff
6.
System Pu p By:
C7ompzm-y
7. Location where contents were disposed.,
I--
'I
Tig-'�tur of___
—a-ier ---- ---
ignature of Receiving Facility —date
15form4,doc.03106
System Pumping Record-Page I of 1