HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 432 SALEM STREET 12/9/2020 Commonwealth of Massachusetts DEC 0 D 2020
__- - z, City/Town of TOWN OF N@THANDUVER
System Pumping Record HEALTH DEPARTMENT
X i Form 4
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, L4 ]
use only the tab J Q.' �•
--
key to move your Address
cursor-do not ` . Andover - ____ - 11214_1�
use the return City/Town State Zip Code
key.
2. System Owner:
r� _ 8 t-j Ss a r j Sit ow o t�) ------ --
Name
Address(if different from location)
City/Town State Zip Code
--
Telephone Number
B. Pumping Record
1. Date of Pumping p f� 2�0 — 2. Quantity Pumped: Gallons 000
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:
6. System Pumped By:
Name semcePumPing&Drain 1U0,,1W Vehicle License Number
S Ha rg Park
�•__ 0u n1164
Company t Nortp*
7. Location where contents were disposed.
C-� - ------- -- - ----- ---
------------------- ------------- ----------
(ti
gnature of r Date
Signature of Receiving Facility(or attach facility receipt) Date
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