HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 2 BRECKENRIDGE ROAD 10/27/2020 Commonwealth of Massachusetts RECEIVED
N _. - -.-._- ,z City/Town of Nor f-I�> pVC
VSystem Pumping Record OCT 2 7 2020
yN`._ Form 4 TOWN OF NORTH ANDOVER
3''� 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 forms 1. System Location:
on the computer, +
use only the tab
key to move your Address
cursor-donot �\ y l �� p r 1 U G` � -S
key,use the return
urn City/Town `1 1 State L Zip Code 0
2. System Owner:
IL If _N 13 c-rn so r,
Name
rr,^✓n
Address(if different from location)
City/Town State Zip Code
_ q
'Telephone Number
B. Pumping Record
1. Date of Pumping Date G 2. Quantity Pumped: Gallons' �
3. Component: ❑ 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. Observed condition of component pumped:
(% 1C
6. System Pumped By:
A Sty y1 t o S' ---_ iQ R I "7
Name Vehicle License Number
,,?vice Pumping&Drain Ca,Inc.
--._ SNgllhergPartc
Company Notth Reading,MA01864
7. Location where contents were disposed
LS
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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