HomeMy WebLinkAboutTripoli Pizza - Septic Pumping Slip - 542 TURNPIKE STREET 12/9/2024 Town of North Andover
Commonwealth of Massachusetts
CityrTown of NOV k A r-)dcu-er DEC 10 2024
System Pumping Record
Form 4 Health De pa
DEP has provided this form for use by local Boards of Health, Other forms may b use Twphl
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 CIVIR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab
key to move your Address qAq y
cursor-do not A-
use the return Cityrrown State Zip Code
key.
2. System Owner:
Narre
Address(if different from location)
Cityrrown State Zip Code
Telephone Number
B. Pumping Record '57o
1. Date of Pumping 2. Quantity Pumped:
DWP4� Ganons
3. Component: F1 Cesspool(s) F-1 Septic Tank F] Tight Tank Grease Trap
F1 Other(describe):
4. Effluent Tee Filter present? E] Yes P No If yes,was it cleaned? E] Yes 0 No
5. Observed condition of component pumped:
6. System Pumped By:
Name Vehicle License Number
company
7. Location where contents were disposed:
Sl$Ature of Hauler Date
Signature of 4e-c—elving Facility(or attach facility receipt) Date
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