HomeMy WebLinkAboutSeptic Pumping Slip - 1475 TURNPIKE STREET 3/3/2016 Commonwealth of Massachusetts RECEIVED
City/Town of NORTH ANDS V 6 �uB�� ��
System pin cor uoanamrOn
Form 4 HEALT11 DEPARTMEN
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 forms 1. System Location:
on the computer, 1475 TURNPIKE STREET
use only the tab -__ .--. —__-- -- __-- -- ----- -- ---
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
use the return - — -
key. City/Town State Zip Code
2. System Owner:
r� ANDRE BALATKA __--- _-- ----- --
Name
rerean
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
3/3/1__6__ 1500
1. Date of Pumping Date - - 2. Quantity Pumped: G3llons
3. Component: ❑ Cesspool(s) ® Septic Tank ❑ Tight Tank Ci Grease Trap
❑ Other(describe): - - - - - - - - ---
4. Effluent Tee Filter present? ® Yes ❑ No If yes, was it cleaned? Ei Yes L] No
5. Observed condition of component pumped:
GOOD CONDITION
6. System Pumped By:
JAMES H CURRIER II _ H79 406
Name Vehicle License Number
X SEPTIC & DRAIN
Company
7. Location where contents were disposed:
GLSD
f ' 3/3/16
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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