HomeMy WebLinkAboutSeptic Pumping Slip - 157 OLD CART WAY 10/16/2017 RECEIVED
Z
Commonwealth of Massachusetts 1)(1, 1 (3 X111
Cityffown 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 A Or ss
to move your
cursor-do not
use the return 51YN�v';n'
State Zip Code
key- 2, System Owner:
'-
y�
Address-(if-d—ifferent from
CilyrTown State Z' Cc e
-
A
B. Pumping Record Telephone Number
1. Date of Pumping
2. Quantity Pumped:
-date Gallons
3. Type of system: ❑ Cesspool(s) &--Septic Tank El Tight Tank Ej Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? No If yes, was it cleaned? C_alr-e's ❑ No
5. Condition of System:
6 System Pumped By:
Nam '
VehjCI U se Number N A0 e cTT6
Comps/
orcl
7. Loca(A�i
�pAtOvelft?osed-
-Signature of Hauler pate'
signature of Receiving Facility —pate"-
15form4,doc-03/06
System Pumping Record-Page 1 of 1