HomeMy WebLinkAboutGrease Tank - Septic Pumping Slip - 100 WILLOW STREET 9/8/2020 Y Commonwealth of assachusetts
u! City/Town of
System RECEIVED.
FOrm 4 PuMPIng Record SEP 0 8 2R0
aEP has provided this form for-ase by local Boards of Health. Other T T
information must be substantial) the Same TOWN OF NORTH ANDOVER
local Board of Health to determl a the form they that provided here. 8 fo us!'ing the f 9t but the
the local Board of Health or other approving use,The System Pumping m, Check With your
9 authority. P 9 Recortl must be submitted to
A. Facility Onforrmatlo�
Important:
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forms on the _ -� �ocatlon:
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key. Slate
C� 2- System Owner: ZIP Code
Name - P S ec
r Address{if d►frerentfrom focatio n)
CityR'own
State
ZIP Code
i elephone Number
B- Pumping Record
i. Oate of Pumping
Date 2. Quantity Pumped:
I Type of system: Gallons
❑ Cesspool(s) ❑ Septic Tank -
0-Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present?
❑ Yes ❑ No If yes, was it cleaned?
5. Condition of Sys' m: ti
❑ Yes ❑ No
6. System Pumped By.
Name
Vehicle Lfcense Number
r Ze IcS 5 �t
Company
7. Location where contents were disposed:
Signature of Hauler Date
tftrmCdoc-06103
System Pumping Record Page 1 of 1
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