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HomeMy WebLinkAboutSeptic Pumping Slip - 75 WINDSOR LANE 3/3/2016 Commonwealth of Massachusetts RECEIVED ��' rr� City/Town«/nv/ / «// NORTH ANDOVER System Pumping — Tc`~ �� Form 4 � DEP has provided this form for use by local Boards of Health. Other forms may be uoed, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health h)determine the form they use. The Gyabam Pumping Record must be submitted to | the local Board of Health nr other approving authority within 14 days from the pumping date in accordance with 310 CPWR 15.351. A. Facility Information Important:When filling out forms 1. System Location: on the computer, use only the tab 75 WINDSOR key 0u move your xogeau cursor-do not NORTH ANDOVER MA O18�5 000thomuum | key. uitw/mwn State Zip Code / | 2. System Owner: � ~---' KR)8TiNEPERNA Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 5/1/15 15OU 1. Date ofPumping Da Quantity Pumped: �Gallons 3. Component: [l Cesspool(s) M Septic Tank F-1 Tight Tank El Grease Trap E] Other(describe): ! 4. Effluent Tee Filter present? M Yes F1 No /f yes, was dcleaned? Yes No � 5. Observed condition Vf component pumped: GOOD CONDITION / | G. System Pumped By: JAMES H CURRIER U H79 406 Name Vehicle License Number J' 8EPT|C & DRAIN Company 7. Location where contents were disposed: GLSD 5/1/15 8ignatum"6fHauler ` ` ' � Date GignotumofRnueiving Facility(or attach facility receipt) � Date ------ � t5foon4.doc^11/13 System Pump ngRecur4 ' Page 1uf1 Commonwealth of Massachusetts x Cwtyllm vvn of 'jV r1 p' 'aj System i r 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. A. Facility Information 1. System Location: Left/Right front of hour$$;'Le /Righi rear of us )Left/right side of house, Left/ Right side of building, Left/Right front of b "Ilding, Left/Right rear of building, Under deck Address ri City/Town State Zip Code 2. System Owner: Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping cord 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) El—septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes,was it cleaned? ❑ Yes ❑ No 5. Condition of System. 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location where contents were disposed: Lowell Waste Water Sign toe HaulerU Date t5form4.doc•06/03 System Pumping Record a Page 1 of 1