HomeMy WebLinkAboutSeptic Pumping Slip - 58 SALEM STREET 8/2/2018 Commonwealth of Massachusetts 110
City/Town of '27
System Pumping Record NORTH ANDOVER � W
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 thei
computer,use
only the lab key Address
to move your �y�} ,, / p 17��4 t'�
cursor-do not _....s'.`.'. ` �V _._ _ _ �._✓.__�? _",.!._. _ —
use the return Cityrrown State Zip Code
key. 2, System Owner:
Name . ......
Address(if different from location)
GityfTown State `"1 T' ...Z'pp 'c(_.1.... .....
•3'etephone plumber .__.... ...
B. Pumping Record -{
1. Date of Pumping t � 2. Quantity Pumped:
Gallons
3. Type of system; El Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe); _. ___.._ _.._._. _. _ . . .-._
4. Effluent Tee Filter present? [_] Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
_
6. System Pumped By: „�� C,
Vehicle License Number
Company
7. Location where contents were disposed:
Sfgnalure of Hauler 40 _
Signature of Receiving Facility . ..._. .___._. �
i
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