HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 160 CARLTON LANE 6/8/2022 RECEIVED
Commonwealth of Massachusetts
City/Town of JUN 0 S 2022
System Pumping Record FOINN OF NORTH ANDOVER
Form 4 ;C-ALTH 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 I C( Cc- 4on
key to move your Address
cursor-do not I y r, Ay.d-.A-r
use the return City/Town State Zip Code
key.
2. System Owner.
VQIS�c� Q ILwC-
Name
Address(ff different from location)
Cityrrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2.y ZZ 2. Quantity Pumped: 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 pumped:
GQoc� -
6. System Pumped By;
Tlri C tr- V`IJ 2a$
Name 1 Vehicle License Number
Company
7. Location where contents were disposed:
22
Signatur�61' Date
Signature of Receiving Facility(or attach facility receipt) Date
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