HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 232 RALEIGH TAVERN LANE 9/3/2020 RECEIVED
Commonwealth of Massachusetts SEE 0 3 ?02 0
City/Town of Nov- -h And over TOWN 0F NORTH ANDUVER
E _ System Pumping Record HEALTH DEPARTMENT
Form 4
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 1. System Location:
�r�•
forms on the
computer,use a?:� K
only the tab key Address
move your c �oY-�n
use the return
cursor- not City/Town State Zip Code
key. 2. System Owner:
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping _ 2. Quantity Pumped:
Date XSeptic
Gallons
3. Type of system: ElCesspool(s) Tank ❑ Tight Tank ElGrease Trap
ElOther(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
f
6. System Pumped By:
Name l , -^E Vehicle License Number
tQ\J�(J
Company
7. Location tt where�,coo-n-tee-ntts�were disposed:
�TW— J 1 �
Signature of Hauler Date
Signature of Receiving Facility Date
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