HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 160 FARNUM STREET 9/3/2020 Commonwealth of Massachusetts RECEIVED
City/Town of NO�r-V" Ar)dCVer SEP 0 3 ?U20
System Pumping Record TOWN OF NORTH ANDOVER
/,. Form 4 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 the `iuo
computer,
r,use
only the tab key Add O
to move your \/� Q�
cursor- not City/Town \ State Zip Code
use the return
key. 2. System Owner:
�1 morn
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped: 1000
Date Gallons
3. Type of system: ❑ Cesspool(s) x
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 Syste t
��or�
6. System Pumped B
Rb ApAk
Name Vehicle License Number
Company
7. Location where contents were disposed:
RIWCP
Signature of Hauler Date
Signature of Receiving Facility Dale
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