HomeMy WebLinkAboutSeptic Pumping Slip - 651 TURNPIKE STREET 11/27/2017 ILX Commonwealth of Massachusetts
a 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 rrlling out 1. System Location:
forms on the ,
computer.use
_. ---only the tab key Address •- r to moveour
cursor. -141_1-nol ._.._.
use the return Citylrown Stale - Zip Code —
key.
2. System Owner:
Name
Address(if different from location)
State
Zip Code
T -e r �_C�.7 .... _. ..
Telephone Number
B. Pumping Record
1. Date of Pumping --._t..T_ —`
2. Quantity Pumped: Gallons —
3. Type of system: ❑ Cess000l(s) ❑ Septic Tank ❑ Tight Tank
❑ Grease Trap
{ ] Other(describe): •L.( ..__... __ _._.._... .. ._...-.
4. Effluent Tee Filter present? ❑ Yes No if yes, was it cleaned? [] Yes ❑ No
5. Condition of Syste :
-------- •--
6. System Purnped By:
(-
Name vehicle t.feense t�vumt)e�, -
Company .. .......... .__..._•----
7. Location where contents were disposed:
Signature of Hauler Date- ----- ...
Signature of Receiving Facilfty i"✓C �Y t]ate
h
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