HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 80 LACONIA CIRCLE 9/3/2020 RECEIVED
`\ Commonwealth of Mas achusetts
94 City/Town of NOVA n AM ovu 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: C
forms the
computer,use Law
8o �
n
only the tab key Address r ,4� o
to move your ft\V1� � (� M O'� �
cursor- et not City/Town i_ State Zip Code
use the return
key. 2. System Owner:
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) Xseptic Tank El Tight Tank ❑ Grease Trap
El Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. Syst---�pe y.
Name , i Vehicle License Number
Company W
7. Location where Lantents were disposed:
Signature of Hauler Date
Signature of Receiving Facility Date
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