HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 203 BOXFORD STREET 12/9/2020 �-L\ Commonwealth of Massachusetts
City/Town of RECEIVED
System Pumping Record
Form 4 DEC 0 9 202U
M TOWN OF NORTH ANDOVER
DEP has provided this form for use by local Boards of Health. Other forftFn NtW ';#fit 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, — -7
use only the tab
key to move your Address -
cursor-do not
use the return key. City/Town State Zip Code
2. System Owner:
ras 11
Name
rmm
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 6 Date/ / �U 2. Quantity Pumped: Gallons Qt�
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? 4 Yes ❑ No If yes, was it cleaned? � Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Name Vehicle License Number
Company
7. Location where contents were disposed:
Signature of Ha ler Date
Signature of Receiving Facility(or attach facility receipt) Date
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