HomeMy WebLinkAboutTripoli Grease Trap - Septic Pumping Slip - 542 TURNPIKE STREET 4/16/2025 Town of North Andover
IL 2 2 2025
Commonwealth of Massachusetts APR
City/Town of LILA-h ArjaWe,(-
System Pumping Record Health DepartMent
Form 4
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
a=rdance with 310 CMR 15.361.
A. Facility Information
Important:When
Nwv out forms 1. System Location:
on ft computer,
U110 Only ft tab I
—5N I I
key to mova your Address
oursor-do not
use the relum MA
key. Wrom —
01 -state zip Code2. System Owner.
VD:�A —rrli P(Ai
+ tF
Adftsiiii(Iii!dim III location)
Cky/Town state code
B. Pumping Record
1. Date of Pumping Lit
LABOR 2. Quantity Pumped: Gag=
ALI
3. Component 11 CeSSPOOKS) D Septic Tank F_1 Tight Tank Grease Trap
0 Other(describe) ......
4. Effluent Tee Filter present? E] Yes No If Yes,was it cleaned? n Yes El No
5. Observed condition of component pumped:
6. System Pumped By:
Nerve Vehicle Ucense Nuffbar
(49 ony
7. Location where contents were disposed:
of Waff t A*k Al 1611-5-
t- Date
signature Of Receiving Facility(or attachfacafty�reoelpQ Date
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