HomeMy WebLinkAboutGrease Trap - Butcher Boy - Septic Pumping Slip - 1077 OSGOOD STREET 7/14/2026 Commonwealth of Massachusetts Town of North Andover
City/Town
SYStem Pumping Record JUL 2 1 202
Form 4
DEP has Provided this form for use by local Boards of Health. OtheAgIth Deeartment
Information must be substantially same as that provided here, Before using`tMay h s form, check with o
sod, but the
local,t3 of Health to determine the form they use. The other
ur
the at of Health System Pumping Record Must be submitted to
accordance with 310
or authority within 14 days from the Pumping date in
1J CHAR 15.351.
A. 1=acility Information
knPOrtaftWhen
flung out forms I. SystemLocation:
on the
tyr the tab
use on your
computer,
low to move
cursor-do not
use Ow return
,
!Town
2. System owner:. state
Ip Code
AdOreas(tf differant from location)
C�fyr/7'own
State Zip Code
Telephone NumberPumping nl n Ord
1. bate of Pumping " i p
Datw 2. Quantity pumped:
�. Component: [� pool(s)
El Septic Tank 0 Tight Tank Grease Trap
Other(describe):
4. Effluent Tee Filter present? 0 Yes 0 No
If yes,was it cleaned? D Yes 0 No
5. Observed condition of component Pumped:
5 Sy m Pumped By:
�nC
N
Vehicle License Number
Company
7. Lo ion where contents were disposed:
4" y
Sign n�c of Hautr�r
signature of firing Facilky(or affach facility rec Ctate
Wbm)4.dOC-11/12
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