HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 2050 SALEM STREET 9/3/2020 RECEIVED
Commonwealth of Ma sachusetts SEP 0 3 Z020
A City/Town of 1 Voy mf
- _� System Pumping Record TOWN OF NORTH ANDOVER
r HEALTH DEPARTMENT
w 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:
forms on the
computer,use
only the tab key Addr s
to move yourwwr
1
cursor-do not
use the return City own State Zip Code
key. 2. System Owner:
�1�r
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: 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:
All
6. Syste Pumpe By:
Name Vehicle License Number
J
Company
7. Location ere co tents were disposed:
P�tC�T")
Signature of Hauler Date
Signature of Receiving Facility Date
t5form4.doc•03106 System Pumping Record•Page 1 of 1