HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 102 PENNI LANE 7/15/2020 RECEIVED
Commonwealth of Massachusetts
City/Town of _jL,gnd UV�— JUL 15 201.0
_ . System Pumping Record TOWN OF NORTH ANDOVER
Form 4 HEALTH DEPARTMENT
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
key to move your Address
cursor-do
et not /V , A� �o v e l /1 O i� T s
use the return City/Town/Town (`�l
key. y State Zip Code
2. System Owner:
►-, ate, Iles - AVa -
�� t 1 GZ
Name
Address(if different from location)
City/Town State Zip Code
(U - -7-13 - oi`i�2
Telephone Number
B. Pumping Record
1. Date of Pumping Date a 2. Quantity Pumped: +`71�L�
Gallons
3. Component: ❑ Cesspool(s) V- 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: C�J �rl
6. System Pumped By:
N_n 17ray P 9 �`Ll
Name Vehicle License Number
Service Pumping&Drain Co. Inc.
Company
North Readio&MA 01864
7. Location where r�(tsfv�retNs 'Sed:
Sig ure of uler Date UILUIa ,
Signature of Receiving Facility(or attach facility recelpt) Date
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