HomeMy WebLinkAboutSeptic Pumping Slip - 78 EQUESTRIAN DRIVE 1/19/2016 Commonwealth of Massachusetts
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 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 17 Eq,
computer,use - — ---- -6 1 ,
only the tab key Address
to move your And, 0'V6(
cursor-do not
use the return ciiyrrown state Zip Code
'ey 2 System Owner,
'�annc,
Name
Address(i!different from IocaUon)
J_X
fT State ZPp C 11
own
Telephone Number
B. Pumping Record
1, Date of Pumping . ..... 2. Quantity Pumped:
Date Gallons
3. Type of system. F—i cesspool(s) [/, Septic Tank
Tight Tank Grease Trap
Other(describe):
.9 (.9'Yes [3 No if yes, was it cleaned? EYes D No
4, Effluent Tee Filter present.
5. Condition of System:
�a- ooj. ... - - - -: . -
6, System Pumped By'.
J)YY)
Name
�vt;( Env r�-oyiyy)c/n-�a
Company
7 Location where contents were disposed:
Signature of Mauler - Date
------- —Date
Signature of Receiving FaCitity System Pumping Reewd Page tad I