HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1300 SALEM STREET 9/3/2020 .�� Commonwealth of Massachusetts RECEIVED
City/Town of NorAAC) Andove Y
System Pumping Record SEP 0 3 Z
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 CM 15.351.
A. Facility Information
Important:
When filling out 1. System Location:
forms to the o O aaLenx� -a--
only '
computer,use c L,_J l.r`�( 1
the tab key Address
to move your N�0r�
use the return
cursor- not City/Town ` State Zip Code
key' 2. System Owner:
1�c�lbach
Name
' Address(if different from location)
CitylTown State Zip Code
Telephone Number
B. Pumping Record0100
1. Date of Pumping (,4 Date--1`=�TW`"�/��f 2. Quantity Pumped: canons
3. Type of system: ❑ Cesspool(s) Xseptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of Syste
Vor k
6. System Pumped By:
CYI.�rC urn l Q.r'k-
Name n �-, Vehicle License Number
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Company �[J�llrJ
7. Location where contents were disposed:
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Signature of Hauler Date
Signature of Receiving Facility Date
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