HomeMy WebLinkAboutSeptic Pumping Slip - 11-08-2024 - Septic Pumping Slip - 225 CARLTON LANE 11/8/2024 Cornmonwealth Of Massachusetts
City/Town Town of North Andover
System PuWing Record
Form 4 JAN 12025
DEP has Provided this form for use by local Boards of Healttj. ottle It
Ime as that provided here., E
infofTnation must bO S'UbstRntially the S, ,ja
I t t ,U- wi
local Uo i jrj of Health to determine the form they use, before nFt ' th your
tile IOC3' Board OtHealth or other approvi,19 authority The System Pumping Record rnust be submitted to
accordance nth310 CMR 15.351, within 14 days from the Pumping date in
A. Facility Infonnation
Important:When
filling Out forms 1. System Location:
on the computer,
use only the tab h:32n Lati e
key to move your Address
cursor-do not
use the return
key. CKYfrown
state
Z System Owner.
'�V V
Name
ZW/T own '--
-Telephone urn"er
P4mping_hfto�rd _
Date Of Pumping
Date 2. Quantity Pumped- ......
3. Component, Gallon3
0 CeSSPOOKS) Septic Tank Tight Tank Grease Trap
El Other(describe):
4. Effluent Tee Filter present? El Yes El No If Yes, was it cleaned? Yes El No
6. Observed condition Of component Pumped:
6- System Pumped By:
Warne
Velk*License_Nu r_
Company
T Location where contents were disposed:
Hauler ------
N ate
Date
Mom*doc 1 1"12
System Pumping Record•Page 1 of 1