HomeMy WebLinkAboutSeptic Pumping Slip - 227 BERRY STREET 10/16/2017 RECEIVED
0(J 16 2017
Commonwealth of Massachusetts
City/Town of I`OWN OF NORTIA ANoOVER
JJEALTH DEPARTMENT
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 L2.)T .`�kc c
only the tab key Address
to move your C)
cursor-do not
use the return City[Town State Zip Code
key. 2. System Owner:
Address(if-different from location}
GityfTown State
C�
-:Telephone Number
B. Pumping Record
1. Date of Pumping C.� ' �- -. Z. Quantity Pumped: — _ -
DateGallons
3. Type of system: El Cesspool(s) [A Septic Tank Ej Tight Tank [I Grease Trap
[3 Other(describe):
4. Effluent Tee Filter present? C] Yes No If yes, was it cleaned? E] Yes L-1 No
5. Condition of System:
6. System Pum
�d By:
CA_
Mame vehicle License Number
Company
7. Location where contents were disposed:
Signature of Hauler ateSignature of Receiving Facility '
e
Worm4.doc-03/06 System Pumping Record-Page i of 1