HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 71 LIBERTY STREET 9/19/2022 Commonwealth of Massachusetts RECEIVED
City/Town of SEP 192022
System Pumping Record
Forl'1'1 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. Sy`stem L•ocatio_n:
on the computer,
use only the tab
key to move your Address
cursor r not � �� jze� mG
use the return Cit frown
key. y State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State ip Code
9 7,F 13
Telephone Number
B. Pumping Record
1. Date of Pumping Date 31 a�2. Quantity Pumped: J
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 dumped:
6. System Pumped By:
Name Vehicle License Number
Company
7. Location where contents were disposed:
Signature of HauleY Date
Signature of Receiving Facility(or attach facility receipt) Date
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