HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 217 GRAY STREET 6/8/2022 RECEIVED
Commonwealth of Massachusetts JUN 0 g 2022
uv_ City/Town of
S stem Pum In Record TOWN OF NORTH ANDOVER
y p g HEALTH DEPARTMENT
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, 21� G(c z
use only the tab
key to move your Address
cursor-do not f.1d �a�� ��, 0 I�'S
use the return Cityrroolwn State Zip Code
key.
VQ 2. System Owner:
Ad Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date /ly 2. Quantity Pumped: Gallon
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:
G6O
6. System Pumped By:
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Name. IVehicle License Number
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Company Ij
7. Location where contents were disposed:
GLS D
L) I Z2
Signature er Date
Signature of Receiving Facility(or attach facility receipt) Date
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