HomeMy WebLinkAboutSeptic Pumping Slip - 80 LACONIA CIRCLE 1/19/2016 Commonwealth of Massachusetts
,tj- City/Town of
System Pumping Record NORTH ANDOVER
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 fon-n,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: I System Location:
4.^len fifling oul orms on the ompute�,use
'.0 � ��cuo.
only the!ab key Address
to move your
curs it-do no' State Zip Code
use the return
ey 2. System Owner:
vt-L-41
Name
�° Address(it different tram location)
dITF/Tov't'n Zip Code
qr7,
0�
Telephone Number
B. Pumping Record
4-5-00-
1, Date of Pumping Date Z. Quantity Pumped, Gallons
3, Type of system. ID Cesspools) R/Septic Tank Tight Tank Grease Trap
Ef Other(describe),
�4. Effluent Tee Filter present? Yes No if yes, was it cleaned? Yes J No
5, Condition of System:
6, System Pumped By: 7 0
Name j"A Envi�-anyY-)CAKAI Vehicle License Number
company
Location where contents were disposed:
001(-W) A
Signature-of tia— er Qate
Srgnaiure o:Receiv+ng Facility Date
System P�jmptng Record-Page I of I