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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 9/16/2019 Commonwealth of Massachusetts RECEIVED W City/Town of NORTH ANDOVER S-F° 16 - i System Pumping Record TOWN OFN©RTHANDUVER Form 4 HEALTH DEPARTMENT M SV a e 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 forms 1. System Location: on the computer,use only the tab 2350 TURNPIKE STREET key to move your Address cursor-do not NORTH ANDOVER MA 01845 use the return City/Town State Zip Code key. 2. System Owner: BUILDING_B Name Bam Address(if different from location) Citylrown State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 8/30/19 2. Quantity Pumped: 5500 Date Gallons 3. Component: ❑ Cesspool(s) ® Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(descl . 4. Ef*!:!E `Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No b. ndition of component pumped: 6. System Pumped By: JAY CURRIER H79406 Name Vehicle License Number J'S SEPTIC & DRAIN Company 7. Location where contents were disposed: GLS �- 8/30/19 nature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doce 11/12 System Pumping Record a Page 1 of 1