HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 50 JAY ROAD 2/3/2022 �L—\ Commonwealth of Massachusetts RECEIVED
City/Town of
z
System Pumping Record FEg 0 3 2022
Form 4
M TO NORTH ANDOVER
HE LTH 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 C M R 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, cQ
use only the tab �� S cA y
key to move your Address
cursor-do not A10 A o o/0 ilc-K G
use the return City/Town Staten Zip Code
key.
2. System Owner:
Name
rvun
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping - 2. Quantity Pumped: l UUo
Date 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 p ped:
k s �,
6. System Pumped By:
Name Vehicle License Number
Company
7. Location where cont nts were disposed:
Signature of Ha r Date
Signature of Receiving Facility(or attach facility receipt) Date
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