HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 263 CANDLESTICK ROAD 9/3/2020 \ Commonwealth of Massachusetts RECEIVED
City/Town of NOV4) An ver SEP 0 3 Z-0?0
System Pumping Record
Form 4 TOWN OF NORTH ANDOVER
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 onthe At _?
computer,
r,use L(l 1.
only the tab key Address
to move your �`WAn An c /P c �/� j,
cursor-do not — L�t L ii.L—lam{ ► ` 1/" t
use the return City/Town State Zip ode
key. 2. System Owner: 0 Y),n
IL Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record 1' 1i
1. Date of Pumping 1:1 lab
D 2. Quantity Pumped: Ga lone
3. Type of system: ❑ Cesspool(s) S/ eptic Tank ❑ Tight Tank El Grease Trap
❑ Other(describe): / 1
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of Sys m:
1' n
6. System Pumped By:
YN111 e. C-a rt�c
Name Vehicle License Number
Company
7. Location w ere contents were disposed:
Signature of Hauler Date
Signature of Receiving Facility Date
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