HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 325 SUMMER STREET 8/8/2019 Commonwealth of Massachusetts RECEIVED
City/Town of.�.An6o\f _v- AUG 0 2019
System Pumping Record TOWN OF NORTH ANDOVER
Form 4 HEALTH DEPARTMENT
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.B
local Board of Health to determine the form th e with your
y use.The System Pumping Record must be afore using this form,check ck wi wi
the local Board of Health or other approving authority within 14 days from the pumping date in tted to
accordance with 310 CMR 15.361.
A. Facility Information
Important:When
filling out forts 1. System Location:
on the computer,
use only the tab l�.F'Yl Irk
key to move your Address
curUse the
returndo . A
key.the velum OIty/Town V V
State
2. System Owner: P code
fliU� i
Name
Address(If different from location)
I
c1tyR own
State � Zip Code�7�5- 8S la- ' !'�I
6. Pum Irt Telephone Number
p� 9 .Record
I. Date of Pumping tyPumped;2. Quanti GG
Date
Gallons
3. Component: ❑ 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. Observed condition of component pumped:
qaa
-11
6. System Pumped By:
. A )��
Name Sentice Pumping&Drain Co.,Inc. Vehicle License Number
Company North Reading,MA01864
7, Location where conten(s we er d posed:
i
rill
nature of Hauler Date
Signaturo of Raosiving Facliity(or-attach facility receipt) Date
i
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