HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 165 MILL ROAD 12/2/2019 Commonwealth of Massachusetts RECEIVED
C ity/Town of LL
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U190 System Pumping Record DEC 0 2 2019
Form 4
TOWN OF NORTH ANDOVER
DEP has provided this form for use by local Boards of Health. Other forms ma HEALTH DEPARTMENT
y 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, ^I
use only the tab _ (�.5 �� I I Rya
key to move your Address
cursor- et not A N r f r , A n Q G
use the return f1 C,t t"'*'� o
key. Cityfrown 45
State
Zip Code
m
2. System Owner:
Name
nun
Address(if different from location)
City/Town State Zip Code
P —] r.Q( n
Telephone Number 'r
B. Pumping Record
1. Date of Pumping 11119110,
Date 2• Quantity Pumped:
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:
(� K
6. System Pumped By:
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Name Service Pumping&Drain Co.,Inc. Vehicle License Number
5H IlbayPark
Company North Reading,MA 01864
7. Location where contents were disposed:
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I I 1C)
Signature of Hauler Date
signature of Receiving Facility(or attach facility receipt) Date
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