HomeMy WebLinkAboutSeptic Pumping Slip - 06-19-2024 - Septic Pumping Slip - 6/19/2024 Town
of NOrth Andover
ommonwea t h of a sachusetts
x City/Town of
System Pumping Record
b_
Form 4 Health DopartMent
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 - :_--
key to move your Ad es
s�
cursor-do not b
use the return
key. Ci yfTown state Zip Code
2. System Owner:
_.._ ._ _-_._ _..__.... ------------
Name
----.._ ......
Address(if different from location)
-- __._._..._...._. __.... d .._.. ... * ...
Cityfrown state Zip Cod„
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date 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 c dition of component pumped:
_._--� -._ --- _..... -- ._ - ------
6. stem Pumped By
Name Vehicle License Number
Company d..
7. Location where contents were disposed:
..
signature o H uler Date
J ---- -- —
f Rene
r
Signature o ivin it Y(or attach facility receipt) Date
.M
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