HomeMy WebLinkAboutSeptic Pumping Slip - 775 FOREST STREET 1/19/2016 -C-\ 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 c)
Important:
When filling out 1. System Location:
forms on the
computer,use
Ad re
only the tab key �Tdr s s
X—Y
to move your
cursor-do not State Zip Code
use the return CityfTown
key. 2. System Owner'.
Name
kddres� (if dlfferent from-foc��Uc )--
City/Town State Zip Code
'Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap
El Other(describe): -------
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes
5. Condition of System:
6. System Pumped By:
Name Vehicle License Number
-Company
7. Location where contents were disposed:
Signature of Hauler Date
Signature of Receiving Facility Date
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