HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 340 FOREST STREET 1/10/2020 Commonwealth of Massachusetts 0 RECEIVED
ED
City/Town of. I A p�(�r JAN 1
2020
System Pumping Record TOWN OF
ANDOVER
Form 4 HEALTH
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, 1+O Fo
use only the tab �S 1— St
key to move your Address
cursor return
not N/ A(:)
use the return .
key. City/Town State
Zip Code
2. System Owner:
k C,- 00 SGn
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number r
B. Pumping Record l
1. Date of Pumping Date I a� 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:
-f-[`. n k b e i Y-1 a C rt. -C h Cd
6. System Pumped By:
Name Veh,de License Number
Service Pumping&Ura,u�.
S Aalthero Park
Company NorthRadiag,MA018tp:
7. Location where contents were disposed:
C L-S
Signature of 7 H#191Date
Signature of Receiving Facility(or attach facility receipt) Date
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