Loading...
HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 113 BRIDGES LANE 9/3/2020 &N Commonwealth of Massachusetts RECEIVED - l City/Town of r,,�Or(�Y) AfyAQVe-Y SEP 0 3 2020 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 1. System Location: forms on the computer,use \ n ► only the tab key Address to /� to move your ��d���(-� A.�f'�ave 1( 1 1 © l tL]� cursor-do not �-1—t t 11�..,L v Y 1tt / t t use the return Cityfrown State Zip Code key. 2. System Owner: VQ -Ind Name Address(if different from location) City[Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 2. Quantity Pumped: Date Gallons 3. Type of system: ❑ 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. Condition of System: r �o r o C' rnji±inn 6. System Pumpe y � ramm Nam Vehicle License Number (j)OE Compan 7. LocatNnE77777_�������� _ Signature of Hauler Date Signature of Receiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1