HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 115 CRICKET LANE 8/3/2022 Commonwealth of Massachusetts RECEIVED
— City/Town of
System Pumping Record AUG 0 3 2022
Form 4 - TOWN OF NORTH ANDOVER
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 ( ; C 4 el:4 ( ✓1
key to move your Address
cursor- not +_ G
use the return
urn Ci•/Town I
key. � -State - Zip Code
' 2. System Owner:
T)1-- C,i s SP
Name
Address(if different from location)
City/Town State Zip Code
o .7 y�-
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped: / O
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes�z No- If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition/of component pumped:
6. System Pumped By:
Name Vehicle License Number
Bo sac z e kt s�.��,'c
Company 7
7. Location where c9ntents were disposed:
Signature of Hauler �� Date
Signature of Receiving Facility(or attach facility receipt) Date
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