HomeMy WebLinkAboutSeptic Pumping Slip - 8-22-2024 - Septic Pumping Slip - 22 BANNAN DRIVE 8/22/2024 Commonwealth of Massachusetts Town of North Andover
xMl City/Town of i
System Pumping Record FEB22
Form 4
DEP has provided this form for use by local Boards of Healt . r t the
information must be substantially the same as that provided here. a ore u i i heck 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 farms 1. System Location:
on the computer,
use only the tab
key to move your Address
cursor-.do not _
lt
use the return .........
key. Ci y own State Zip Code
2. System Owner
VQa b t� del
. .... "_ -
Na e _ -
Address(if different from location)
aty/Town State / Zrp Code
Telephone Number
B. Pumping Record Zq
1. Date of Pumping '__..___ ......... 2. Quantity Pumped: -.__
Date taallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? n Yes ❑ No If yes,was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
.. _.
6, S tem Pumped By
1 _.... G❑ ._... ............... _._.... _ ... ... -
.._ � vehrde License Number
Name
Company
7. Location where contents were disposed:
__._. _.__.. . _—._ ,- _. ___
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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