HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 676 OSGOOD STREET 7/15/2020 RECEIVED
Commonwealth of Massachusetts 2020
City/Town of _ pi=A ►�16 ov i- JUL 15
s '� System Pumping Record TOYN 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, r 7� � Sn C
use only the tab (11 )
key to move your Address �,j p ,� ^cursor- not
use the return N. A n cq a y k- Iv 1 r 5�
City/Town
key. State Zip Code
VQ 2. System Owner:
Name
ream
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
OG G
3. Component: ❑ Cesspool(s) [R 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 t h e., m • rLksh I
6. System Pumped By:
.,.1 21 q ,3 9
Name Vehicle License Number
Service Pump' &Drain Co. Inc.
Company :1 IMDag Park
North Reading,MA 01864
7. Location where 6dt'ftenis-�"rtY�d' died:
D
i lure of Hauler Date a —'
Signature of Receiving Facility(or attach facility receipt) Date
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