HomeMy WebLinkAboutSeptic Pumping Slip - 280 Gray St - 9/24/24 - Septic Pumping Slip - 280 GRAY STREET 9/24/2024 Town Of North Andover
Commonwealt f a s'�ac usetts
City/Town of l FEB 4
System Pumping Record 2oz
Farm 4Health
DEP has provided this farm for use by local Boards of Health.Other farms may bees �
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 316 CMR 15.351.
A. Facility Information
Important:when
filling
out farms 1. System �ac`yatlon.
on
key only
t e tab r Address
computer,
use only the tab �q �r
Y Y a�. k. .. .. _ 1 _ ..... _._ State. .._..
_ _. Zwp Code
cursor-do not
use the return tyfTown
key.
2. y m owner:
r
Name
erJ�NCar
Address(if different from location)
City,Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date .._.. _ 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) FeSeptic Tank ❑ Tight Tank ❑ Grease Trap
❑ ether(describe):
4. Effluent Tee Filter present? ❑ Ye No If yes,was it cleaned? M Yes ❑ No
5. Observed co dition of component pumped:
_._.- _..._._ _.._. ........--
6. System Pumped ByOq
ame ` Vehicle License Number
Company
7. Location w re ontents were disposed:
_.........
.
a- .
Si ature o Hauler > Date
Signat4eofR wing.Facility(or attach facility receipt) Date
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