HomeMy WebLinkAboutSeptic Pumping Slip - 314 REA STREET 10/16/2017 RECEIVED
C�x Commonwealth of Massachusetts o,'I' 16201,I
City/Town of j0WM OF NORTH ANDOVER
IjDEPA
System Pumping Record NORTH ANDOVER EALTH RTMENT
Form 4
DEP has provided this form for use by local Soards 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 Address
to move your ,V1
cursor-do not
use the return Cilyffown State
Zip Cnde
key. 2. System Owner:
C-�
Name
Address
different from
...........
State-- Z" Code
Telephone
—
B. Pumping Record
(�
1. Date of Pumping Datce --o-My Pumped,
Gallons
3. Type of system: ❑ Cesspool(s) [Septic Tank El Tight Tank Ej Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? Ej Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
QP
S. System Pumped By:
C
Name
Vehicle License Number
Company
7. Location where contents were disposed:
l5form4.doc-03106 North Andover, MA.
System Pumping Record-Page I of I