HomeMy WebLinkAboutSeptic Pumping Slip - 29 GRANVILLE LANE 10/16/2017 RECEIVED
Commonwealth of Massachusetts 1 (3 ?01"1
City/Town of
TOVN OF NORTH ANDOVER
H DEPARTMENT
System Pumping Record NORTH ANDOVER �jEAU
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 Locat' n:
forms on the
computer.use
only the tab key
to move your
cursor-do not
Cily[Town
use the return State v Zip Code
key. 21 Syste Owner:
Mame
Address(if different from loc ation)
'
C.
Ityrrown State zipCide
B. Pumping Record 'fetti�hone Number
1. Date of Pumping AqJ?Quantity Pumped: ---
Date Gallons
3. Type of system: ❑ Cesspool(s) OSeptic Tank El Tight Tank ❑ Grease Trap
[D Other(describe):
4. Effluent Tee Filter present?A'-Yes ❑ No If yes, was it cleaned? (Aes Ej No
5. Condition of System�
C cx)
6. System Pumped By:
C' C
Vwt�lc-le License Number
I.W.WT.P.
10-
0 nts were disposed: jp>�Wighl MA.
gnature 0f Hauler`- Date
Date ......
ignalure Receiving -Da� e
-g
t5foirn4.doc-03/06
f
System Pumping Record-Page t. of i