HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 498 SALEM STREET 6/8/2022 AECEIVED
�L\ Commonwealth of Massachusetts JUN 0 8 2022
City/Town of 4 jRTH ANDOVER
System Pumping Record :..i:TH GEPARTMENT
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, ,�� J.�
use only the tab
key to move your Address _
cursor-do not N 0, "f Ma 6l�`"►`�
use the return City/Town State 2Ip Code
key.
2. System Owner.
Q Ix a LL bOnrarG.,
Name
wa
Address(if different from location)
City/lbwn State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2_ 2. Quantity Pumped: Gal
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes PrNo If yes,was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
G; d VL, Z-62
Name 1 !'� vehicle License Number
QI--�+ I u 10l-N
Company
7. Location where contents were disposed:
C,GS t)
it zz-
Signatunirof Hd& Data
Signature of Receiving Facility(or attach facility n3ceipt) Date
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