HomeMy WebLinkAboutgrease trap - Septic Pumping Slip - 700 CHICKERING ROAD 9/3/2020 RECEIVED
Commonwealth of Mass chusetts
City/Town of N
�Y-bhpn6ove, SEP 0 3 2020
I � ' System Pumping Record TOWN OF NORTH ANDOVER
_y `. 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 —^Y c O
computer,use 1�J
only the tab key Addr�O���� ,,�, n
to move your
cursor-do not CityfTown 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 2. Quantity Pumped: D
Dale Gallons
3. Type of system: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank XGrease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System,
Coo'(-y uond On
6. Syste um ed \Cy Bj.,
Name ( Vehicle License Number
Company
7. Location where
fo`nte�nts were disposed:
Signature of Hauler Date
Signature of Receiving Facility Date
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