HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 125 WINDKIST FARM ROAD 10/19/2021 Commonwealth of Massachusetts
e1 City/Town of _ \Jc)v AndLo\ftr,
- . System Pumping Record
Form 4 TOWN OF NORTH ANDOVER
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, L r
use only the tab a`� ( ►mod K I S f` Rb y- aY
key to move your Addresscur q use
the
- et not A�6 U \(r NA A C) ( RL S
use the return ',�-�.
key. Cityrrown State Zip Code
2. System Owner:
m
Nam �1 V\(3 kt St Eq u_e s+y/ajn Ce ntr ►-
Address(if different from location)
Clty/-Town State Zip Code
q -7a - 37S- SQtt
Telephone Number
B. Pumping Record
1. Date of Pumping Da eo ( I— 2. Quantity Pumped: I U G( —
Gallons
3. Component: ❑ Cesspool(s) K-11 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:
GC>o�
6. System Pumped By:
Name \ Vehicle License Number
4 rvco p„mP;nB&Drain Ca,into.
5 Hall6taaPuk
Company North ReridittE,MA01E64
•....,:yam 6....«...�.e�,.w�..
7. Location where contents were disposed:
Signature of Hauler Date
I —" I E J a
Signature of Receiving Fatality(or attach facility receipt) Date
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