HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 301 SUMMER STREET 10/16/2019 Commonwealth of Massachusetts RECEIVED
City/Town of r (CVC_v-- OCT 16 2019
System Pumping Record
Form 4 TOWN OF NORTH ANDOVER
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 our
local Board of Health to determine the form they use.The System Pumping Record must be submitted
the local Board of Health or other approving authority within 14 days from the pumping date In y
accordance with 310 CMR 15.351. to
A. Facility Information
Important;When
filling out forms 1, System Location:
on the computer,
use only the tab
key to move our Y c,
Y Address
cursor-do not \/
use the return
key, Cityriown I� l
2. System Owner: state Zip Code
Name
aAu
i
Address(if different from location)
State Zip Code
B. Pumping Record Telephone Number
1. Date of Pumping -7
Date 2. Quantity Pumped: ��o("J
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:
- t!
6, System Pumped By:
� i S ue
Name
Service Pumping&Drain Co,,Inc. vehicle License Number
Company North Reading,kt, (@IRc�
7. Location where co nta war fsposed: `
��. lr�
Signature or - Date -
Signature of Recelving Facility(or attach facility receipt} Dat—e —
t5form4.doc•11/12
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