HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 99 RALEIGH TAVERN LANE 9/3/2020 RECEIVED
r Commonwealth of Massachusetts SEP 0 3 U"..+3
- � City/Town of
N04\� over TO WN OF NORTH ANDOVER
Cr - _:, System Pumping Recor HEALTH DEPARTMENT
'r
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 on the pp
Lo
computer,use fr�c 0 1
only the tab key Address
to move your NOy'�n Andover NA 01bL45
use the return cursor- not City/Town State Zip Code
key. 2. System Owner: ,
rJ6 honn in
Name
Address(if different from location)
City[Town State Zip Code
Telephone Number
B. Pumping Record [ (�
1. Date of Pumping —i-- -F�0 2. Quantity Pumped: 1500
Date Gallons
3. Type of system: ❑ Cesspool(s) XSeptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Q No if yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
&�D BaAl
Name j 1 Vehicle License Number
Company
7. Location where
contents were disposed:
V��
Signature of Hauler Date
Signature of Receiving Facility Date
t5form4.doc•03/06 System Pumping Record•Page 1 of 1