HomeMy WebLinkAboutSeptic Pumping Slip - 160 FARNUM STREET 1/19/2016 Commonwealth of Massachusetts
CitylTown of
-- System Pumping Record NORTH ANDOVER
-- Form Q
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
accordance with 310 CMR 15.351-
A. Facility information
Important:
When filling out 1. System Location:
forms on the
computer,use C .o YY'\0 "
only the tab key Addres p
to move your 3 �
cursor-do not CilyfTo///wn - _ - State Zip Code
use the return
key. 2. System Owner:
Name
_.._
Address(if different from location)
--- - -
Cityfi-own Stale Zip Code
Telephone Number
B. Pumping Record
to r t (CSC)_-
Date _
1. Date of Pumping at e( 3� ---- Z. Quantify Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No if yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Wind River Environmental
- -- —- 163 Western Ave:
Name Vehicle License Number
------_. ._G10 '{er,_MA 01930_
Company
7. Location where con eats were disposed:
Signature of Hauler Date
Signature of Receiving Facility Date
15form4,doc•03106 System Pumping Record-Page i of i