HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 740 FOREST STREET 9/3/2020 RECEIVED
au- Commonwealth of Massachusetts
SEP 0 3 2020
City/Town of NAY- -1n AT'&Ntr
.. .j = System Pumping Record TOWN OF NORTH ANDOVER
Form 4 HEALTH DEPARTMENT
�.r
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 D 1 D F )Te a*
computer,use O l L S1
only the tab key Address
to move your
cursor- not 'Norl"') Andover MA ��
use the return c City/Town State Zip Code
key. 2. System Owner:
Name
Address(if different from location)
Cityrrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Datell2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ASeptic 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: t
6. System Pumped By:
rWt) Lar
Name t l ht Vehicle License Number
W l�
Company
7. Location
pwhere contents were disposed:
t'1 i V p
Signature of Hauler Date
Signature of Receiving Facility Date
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