HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 328 FOREST STREET 9/3/2020 °� Commonwealth of Massachusetts RECEIVED
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34 City/Town of Nor-wl Andover 5EP
System Pumping Record
r TOWN OF NORTH ANDOVER
Form 4 H€gTH DEpARTMENT
REP 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 p the
computer,
r,use
only the tab key Address1^
c move your {NJ` � 1 � )d n u {�/�A
cursor- et not City/Town t�1LM�ILLS St-ate Y 1 Zip Code
use the return
key. 2. System Owner: -
Name
Address(if different from location)
Citylrown State Zip Code
Telephone Number
B. Pumping Record 1
1. Date of Pumping � L-1� 2. Quantity Pumped: -��)O
Date 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:
• 1
lan
6. System Pumped By:
hexe k A047
Name Vehicle License Number
1
Company
7. Location wh�pntents were disposed:
Signature of Hauler Date
Signature of Receiving Facility Date
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