HomeMy WebLinkAbout- Septic Pumping Slip - 1424 SALEM STREET 6/20/2019 uommonwt-vulth
t"Jl�,,,J N 2
City/Town of
.iSystemPumping
r wrmmnmmw n i T
OWN OF NORTH ANDOVER
ForHEALTH Dk':PA:RTMEW
m
DE ' has provided this form for use by local Boards Health. Other forms may, be used, but the,
information must be,substantially the,same as that provided here. Beforesing,this form, check with
your locals Board of Health to,determine the form they se. T e System Pumping record must be
submitted t ► the local Board of Health or other approving authority within 14 days from the pumping `
data in accordance with 310 CIVIR 15.351
A. Facility Information
Important: 1. System Location
When filling out
forms on the
computer,use �
w
only the tti
key to move
your cursor
do not use the
w
r;
2. System Owner:
MA
urn + 1"P k F"i I
i
f
Gi stet
Z -God'
i
' �Gi
Tell .
B. Pumping Record
1CAP
Cate Pumping 2n antic umu a : G �
. Componeftw C ss ' of s Septic Tank Tight Tank Grease Trap
Other(des,cri�be):
4. Effluent Tee Filter present? Yes (l!)? It yes, was it cleaned? Yes No
5. Observed condition of component pumped:
U I
t5foirm,4.doco 11 System'Pumping Record Page 1 of
c,
uommonwealth
City/Town
System Pumping Record
ry
Form
Af
DEP has provided this form for use by local Boards of Health.. Other forms may be used, but the
information rust be substantially the,same as that provided here.. Before using this fora, 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 plumping
date in accordance with 310 CMR 15,3511,
6, System Pumped y
,r
Name— Vehiole
4!T
j ,
w,
PC. I6 r�C,.
G+ rn ,m. .
. Location where contents were ispose -
(.r'7-7 if
r 1rt
i
l
i
f
t5form,4.doco 11,112 System Pumping Record Page 2 of 2