HomeMy WebLinkAboutgrease tank - Septic Pumping Slip - 100 WILLOW STREET 6/4/2020 COmmonweaith of Massachusetts
City/ 'own of
SYStem PUMpeng RecordRECEIVED
Form 4 JUN 0 4 20-20
DEP has provided this form for use by local Boards of Health. Other pWN OFF NORTH ANDOVER
information must be substantially the same as that provided here. Before using this form, the
local Board of Health to determine the form the use �- �����T but the
ur
the local Board of Health or other approving y use. System Pumping Record must be submitted ck with oto
PP g authority.
A. �a�al�f� �nf®rra�a�i®try
Important.
When filling out 1_ System Location:
forms on the
computer,use
only the tab key Address
to mo.wyour
cursor-do not
use the return CitylTown
key. �' state 2• System Owner: Zip Code
Name
rrtm Address(if different from location)
City/Town
State Zip Code
Telephone NumberY 7v 3
(�. Pump—in-9 Rec0lrd
1. Date of Pumping '� b 3 O��/Date 2. Quantity Pumped:
3- Type of system: Gallons
❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes
❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: a.
6. System Pumped By;
Name
Company Vehicle License Number
2e ID S 5� 4,c
7. Location where contents were disposed:
ise�Gi�� /c
Signature of Hauler Date
t5forrn4.doc-06103
System Pumping Record-Page 1 of 1