HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1451 OSGOOD STREET 6/8/2022 RECEIVED
IL Commonwealth of Massachusetts
City/Town of JUN p g WZ
System Pumping Record TO\NN OF NORTH ANDOVER
Form 4 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-do not No,
use the return City/Town State Zip Code
key.
m
2. System Owner:
Name
repm
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping J I Z2 2. Quantity Pumped: low
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): —
4. Effluent Tee Filter present? ❑ YeSO No If yes, was it cleaned? ❑ Yes)?I No
5. Observed condition of component pumped:
6. System Pumped By.
Name Vehicle License Number
GtGe t?IVA-6rg
Company
7. Location where contents were disposed:
C�(�J 0
.
Signature- D
Hau r Date
Signature of Receiving acility(or attach facility receipt) Date
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