HomeMy WebLinkAboutSeptic Pumping Slip - 100 REA STREET 10/16/2017 RECEIVED
Commonwealth of Massachusetts X1 16 ?017
City/Town of TOWN OF NORTH ANDOVER
System Pumping Record NORTH ANDOVER �EALTH 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 15,3511.
A. Facility Information
Important:
When filing out 1. System Location:
forms on(tie
computer,use J (9,()
only the tab key Address
to move your
cursor-do not
Zip Code
use the return Ci yrf�-" (5 1.5 tU
key. 2, System Owner:
rl— y- cz V V
Name
Address Wfjl—fferent fromlocation)
Ity(Town State Zip Code
Te--Ie-f;-h—o—nce
B. Pumping Record
1, Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type of system: CD Cesspool(s) Septic Tank F-1 Tight Tank ❑ Grease Trap
2116ther(describe): Rol"?
4. Effluent Tee Filter present? ❑ Yes Pg—wo— If yes, was it cleaned? ❑ Yes
5. Condition of System:
6. System Pumped By:
Vehicle License Number
Company
7, Location where contents were disposed: I.WWT.P.
Ipswich, MA.
4
nature�R Hauler Date
�ignalure Receiving ng Facility Date
'
I$form4.doc-03106
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