HomeMy WebLinkAboutimage (2) Commonwealth of Massachusetts
City/Town of
System Pumping Record NORTH ANDOVER
Forth 4
DI=P has provided this form for use by local Boards of Health. Other farms may be used, but the
information must be substantially the same as that provided here. Before: rising 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 Beard of Health or other approving authority within 14 days from the pumping date in
scGordance with 310 OMR 15.351.
A. Facility information
Important'
Men filling owl System Location:
forms on the L
cornpuler.use _ ,— - .1,�.' 4 `..Ql._.only The lab key Addre
to rrlove your _�
cursor-do not -- Sta3e Zip Code
use the return city f Ours
Key. 2. System Owner:
different Address(€f di
n.ff --- from€oca(ian)
.Cityffown._.—... State ZipCBtlE
B. Pumping Record
Date of P .�_ ?- uantity Pumped:
7 0 Pumping P Date Gsons
3- Type of system: ❑ cesspool(s) optic Tank 0 Tight Tank E] Grease Trap
❑ Other(describe)'
4. Effluent Tee Filter present? Q Yes t'w� if yes, was it cleaned? Q Yes ❑ rya
5. Condition of System:
6. System Pimped By:
Wind River EnviranmomW
---.�..�...,--••� Wpm .. . ...�_ �. - ---
lLiCe'rl_se—...---- - --, n — --
l4�rrte �+! pip VehiGe� Num4er
Company
7. location where co tents ed:
s€gRalu Hauer �$l �
grtatcsre of Receiving f=acility' Date
l5form4.dacc 03)08 System Pumping Record•Page i of 1