HomeMy WebLinkAboutSeptic Pumping Slip - 131 CRICKET LANE 10/16/2017 RECEIVED
Commonwealth of Massachusetts
C o c,'r I
- own of
ity/
TOWN OF NOANDOVER
System Pumping Record NORTH ANDOVER RTIC
Form 4 HEALTH DEPARTMENT
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:
Wnen rifling out 1. System Location:
forms onthe
computer,use CC( Lev
only the lab key Address
to move your
cursor-do not
use the return Cit y(Town
key. 2. Syst&�Owner: State Zip Code
P _ _.__ __. __. .
Name
Addre T(if different from'location)
'dity/'row'n State
Telephone;—NL;—rr1CWr------
B. Pumping Record
1. Date of Pum to 17
p
-Gat- 2. Quantity Pumped:
Date Gallons
3. Type of system: 0 Cesspool(s) Septic Tank Q Tight Tank ❑ Grease Trap
E] Other(describe):
4- Effluent Tee Filter present? Q Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of SystevU
6. System
d B
� W.W.T.P-
Vehidl–D
Company
ich, MA.
7, Location where contents were disposed:
Signature of lia er0.ate
Signature'----
o'f R e c e—iv;,n--g—Fa-c–i I i*I—y -D-'at-e*'
15form4,doc-03/06
System Purnpfnq Record-Page 7 of 1