HomeMy WebLinkAboutSeptic Pumping Slip - 646 FOSTER STREET 10/16/2017 RECEIVED
Commonwealth of Massachusetts TOWN OF NORTH ANDOVER
HEALTH DEPARWENT
City/Town of
M_
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 Lo tion:
computer,use
forms on the
only the tab key
to move your
cursor-do not �_.r• ' l L - C� !7
use the return i�ttyl_/Tow'n State Zip 66e*
key, 2. Syste w e
Name
"'° Address(ifd'rfferent from location) �• „•-- -_--
State
Telephone tNu b�_er
B. Pumping Record
1. Date of Pumping
Date 2. Quantity Pumped:
Gallons
3. Type of system: ED Cesspool(s) Q Septic Tank Q Tight Tank 0 Grease Trap
[] Other(describe):
4. Effluent Tee Filter present? Q Yes No If yes, was it cleaned? 0 Yes Fj No
5. Condition ystem:
6, System Pd By:
—MP C
Name '�W�i_ciel_icense'f4��6e_r__'
V7--p.......... ...-
pp
7. Location w1*10 Company _., PO r sposed:
0183,6
15fo(m4,doc-03/06
System Pumping Record-Page 9 of I