HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 30 VEST WAY 6/8/2022 RECEIVED
Commonwealth of Massachusetts
C JUN 0 8 2022
ity/Town of
System Pumping Record TOWN U�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, 3o
use only the tab
key to move your Address _
cursor-do not No, t-Aa
use the return City/Town State Zip Code
key.
m
2. System Owner:
aC4� iA-i SIN�MOrs
Name
nrm
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record t4 /,1 /-42-1. Date of Pumping 2. Quantity Pumped: I o
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ YeszlNo If yes,was it cleaned? ❑ Yes No
5. Observed condition of component pumped:
6. System Pumped By:
J t ��►0 r V y ZO$
Name Vehicle License Number
G���d I��J�n�InC1
Company
7. Location where contents were disposed:
q 2 2.
Sigr1rature of Date
Signature of Receiving Facility(or attach facility receipt) Date
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