HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 236 SUMMER STREET 9/3/2020 1 Commonwealth of Massachusetts RECEIVED
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ik, 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 C Lkmm ar
only the tab key Address
to move your �`J✓�� �/���v�Y V�� ����S
cursor-do not City/Town State l 1 Zip Code
use the return
key. 2. System Owner:
I-oKen
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record }
1. Date of Pumping 01 Date � ap 0 0
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:
waru h cand�,b.00
6. System Pumped By:
Iffia mm ( a
Name Vehicle License Number
Company
7. Location where contents were disposed:
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Signature of Hauler Date
Signature of Receiving Facility Date
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