HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 66 SUNSET ROCK ROAD 9/3/2020 Commonwealth of Massachusetts RECEIVED
- � City/Town of *rf h d aver
SEP 0 3 f'020
'0 _ System Pumping Record
Form 4 TOWN OF NORTH ANDOVER
.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 POCI
computer,use �� nSD�"(f"
only the tab key Address
to move your Na rfh Nde a L
cursor-do not use the return City/Town State Zip t6de
key.
2. System Owner:
VQ larshol1I
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping C Date 2. Quantity Pumped: Gallo
ns
,O O
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:
6. System Pumped By:
IrflarCcd,S Lark,-
Name CAJ VLE Vehicle License Number
Company
7. Location,wihfere}-coontteents were disposed:
�IJ�AJt�t Ll �"
Signature of Hauler Date
Signature of Receiving Facility Date
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