HomeMy WebLinkAboutSeptic Pumping Slip - 975 FOREST STREET 8/2/2018 RECEIVED
Commonwealth of Masts(achuseAts
(j�� C ity/Town of L) V ) qJ
20
Sy _ dStem PumpingRecc►InW
OWN()F NORTH tkNDOVER
Form 4 HULl H DEPARTMENT
DEP has provided this form for use by lrx;al Boards of Health. Other forms may be used, but the
information must be substantially the same at;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 atuthcdo/within 14 days from the pumping date in
accordance with 310 CMR 15.3511,
A. Facility Information
Important:When
filling out forms /5tem Locctiom
on the computer,
use only the tab .. - �2 (
use the return
key to move your Ac dress
cursor-do not
MA
key. Ciyflrown
State Zip Code
2. System Owner:
q 00 A
Uqy
_Nilrn e
Ac vss(if different hom locat(on)
tyiTovin state Zl;rcode
Telephone Numt�er
B. Flumping Record - 1 -
1. Date of Pumping Date j 2 Quantity Pumped: Gallons'...'
3. Component: M CesspoolW f/ Septic Tank M Tight Tank F] Grease Trap
EI Other(d,ascribe):
4. Effluent"ree Filter present? El Yes Vf Nor If yes, was It cleaned? M Yes ❑ No
5. Observed condition of component pumped-
6, System Pumped By:
Nnrna - 2
Vehicle License Number
Y�tRiver E'rivironmental
Company
7, Loc�afion Nhere contents were d) poz3ed: 'Vogmal ww7p
40 8 Pogtor
q
rd,
uler
e' Vi-V
or Otte"f
I jo a iu re�f_R_e Wi-v FCg Facility- I-C;.�-I t-y-r-e cii p t) I...We—
t5forM4,doc- 11/12
System Pumping Record-Fuge 1 of I