HomeMy WebLinkAboutSeptic Pumping Slip - 312 BOXFORD STREET 10/16/2017 RECEIVED
()(,7 16 ,?�j I I
NOR1-HN0Ovf,.-R
Commonwealth of Massachusetts .
HEAD
LTH DAERARTMLNr
City/Town of
ft 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 C,�'?/
only the tab key Address
to move your Q(*cursor-do not
fTown
use the return CityState Zip Code
key,
2. System w n
Address(it different from loca(ion)-
,di—yrro�w- Stat Zip Code
Telephone tu'-m—b e-r
B. Pumping Record
1, Date of Pumping 2, Quantity Pumped:
'Date Gallons
3. Type of system: ❑ Cesspool(s) 'R�Septic Tank El Tight Tank ❑ Grease Trap
[] Other(describe):
4. Effluent Tee Filter present? ❑ Yes V(No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of SystemV
6. System Pu p By:
Name ve"OW urnber
I W? - lt� 60411 VY VV I
-Co—mpany* ...... 40 S Porter St
7. Location where contents ere disposed: Bradford
Ma 0183,,F
-Sf-gna—ture'of -------- 6'ate-
ignature of Receiving pacitity Date
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