HomeMy WebLinkAboutSeptic Pumping Slip - 785 TURNPIKE STREET 10/16/2017 (2) RECEIVED
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Commonwealth of Massachusetts TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
City/Town of
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 Location:
forms on the
computer,use
only the lab key Address
to move your ve_,��
Cursor-do not
use the return Cily[Town State zip Cade
key. 2. System Owner:
iName
Address(if different from location)
CilyFravn State* —i C_a_de__
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
OateGallons
3. Type of system: Q Cesspool(s) Septic Tank ❑ Tight Tank ❑
Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? E] Yes rnj No If yes, was it cleaned? ❑ Yes ❑ No
91
5. Condition of System:
lvc-
6. System Pumped By:
Name Vehicle License Number
'Company-.......
7. Locatio %t ifts were disposed: r1avernm vvvv 1-p
nftel 24
.40,S-Por.ter-St.
signao Date
S 197M 374-2382
Signature of Receiving Facility
15form4.doc.03106 System Pumping Record-Page 1 of 1