HomeMy WebLinkAboutSeptic Pumping Slip - 785 TURNPIKE STREET 10/16/2017 RECEIVED
Commonwealth of Massachusetts OCT 16 201*1
City/Town of
TOWN Or-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. Systerp-ocication:
forms on the
A6
computer,use —--I--- --..5 , /Alp, ...
only the tab key Address
to move your
cursor-do not
use the return City/Town State Zip Code
key. 2 System Ope 9—
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' Gr..
(Ifdiffefrent from location)
ItY own State q�qe
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B. Pumping Record hone;�—N
1. Date of Pumping2. Quantity Pumped'.
6ale Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank Q Tight Tank [I Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
S. Condition f Systefin:
6. System P ed By-
Name -i umbeL'5, r
Company 53��*
7. LocatiorAteliare"S'Peye A444
d Ot,
Signa au r Date
Signature of Receiving FaciPity Date
t5form4.doc-03/06 System Pumping Record-Paget of 1