HomeMy WebLinkAboutSeptic Pumping Slip - 67 STONECLEAVE ROAD 11/27/2017 Commonwealth of Massachusetts
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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 tilling oul 1. System Location:
forms on the
computer,use �._... r`f_ •� Gt(J�,_..�. {�J
only the tab key Addre55
to move your
cursor,do not lrJ (.1
use the return cityrrown Stale Zip code
key.
2. System Owner•
VQ
Name
Address{if different from location)
State •_ ._ ....... ._.--. Zip Code
Telephone Number
B. Pumping Record �J /
1. Date of Pumping F—� 2. Quantity Pumped: ��
Oate Gallons
3. Type of system: ❑ Cesspool($) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): .... . .-. _. -_..._. .... . . .......... .. ._._.. .
4. Effluent Tee Filter present? ❑ Yes 10 No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System
6. System Pumped By:
Name Vehicle License Number
Company
7. Location where contents were disposed:
Signature of Hauler }; Date +y
Signature of Receiving Facility, pate _.. # _
s
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