HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 50 JAY ROAD 1/5/2023 RECEIVED
Commonwealth of Massachusetts
City/Town of 2023
j System Pumping Record .IAN 0 5
Form 4
�'�,� •• -• TOWN OF NORTH ANDOVE
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 CM 15.351.
A. Facility Information
Important:When _�
filling out forms 1. System Location:
on the computer,
use only the tab ti jZ
key to move your Address
not use the
return
key- City/Town return City/Town /7 State ZiP
Code
—� 2. System Owner:
n
Name Ile —
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date . -a-3-.2 2. Quantity Pumped: 0 y
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes VNc}- If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped: i I
6. System Pumped By:
Name Vehicle License Number
Company
7. Location where contents were disposed:
I•la
Signature of Hauer Date
Signature of Receiving Facility(or attach facility receipt) Date
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