HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 500 GREAT POND ROAD 9/3/2020 RECEIVED
Commonwealth of Massachusetts SEp p 3 �020
94 City/Town of �t /�
t `�0� `-'ve TOWN OF NORTH ANDUVER
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:
forms onthe
computer,
r,use
only the tab key Address
�o� n//_�ti,�1( L_ ���
to move your �1
cursor-do not
use the return City/Town State Zip Code
key. 2 System Owner:
Ca &m Uakb-
Name
Address(if different from location)
Cityfrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: allons
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 Syste :
a
6. Syst Pumped By:
-�- t
Name WEE Vehicle License Number
Company
7. Location where onn't nnls were disposed:
Signature of Hauler Date
Signature of Receiving Facility Date
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