HomeMy WebLinkAboutSeptic Pumping Slip - 18 MARGATE STREET 11/27/2017 Commonwealth of Massachusetts
City/Town of
System Pumping Record NORTH ANDOVER
` Forth d
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 clays 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 move your
cursor do not
use the return CitylTown State -
Zip Code
key.
2. System Owner:
Name .a
Address(if different from location) ---
Stale Zip Code—
?'efephone Number
B. Pumping Record 1
1, bate of Pumping -date
— r - 2. Quantity Pumped: -
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Crease Trap
❑ Other(describe): ••• •- - -• _ __..
4. Effluent Tee Filter present? ❑ Yes C�V No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System-
8, System Pumped By:
Name r Vehicle License Number
Company
7. Location where contents were disposed:
Signature of Hauler -Da.__te-.. . . _...—._..W ._....
e "-
'VI
Signalure of Receiving Fecilily Date ,I
.P- -
'pswich, MA.
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