HomeMy WebLinkAboutSeptic Pumping Slip - 1213 SALEM STREET 3/19/2016 Commonwealth of Massachusetts REECEIVED
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System Pumping r
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Form 4 HEALTH DC.h°IARI'°Hk:f°�"L.
- s DEP 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 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,
use only the tab 121.3 SALEM STREET------------------------------------- _..------------
key to move your Address A 01 L4 M 5
cursor-do not NO_RTH_ANDOVER - -_-- ---
use the return — ------------------------ State
Zip Code
City/Town
key.
2. System Owner:
«a
WILLIS LARSON—-----------------------— --— — --
Name
Address(if different from location)
-------------------- State ---------- -Zip Code -----
CitylTown
Telephone Number
B. Pumping Record
3/19/16- _-_-- 1500 --_-_---.
1. Date of Pumping 2. Quantity Pumped: Gallons
Date
3. Component: ❑ Cesspool(s) ® Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): ------------------ -------- —
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
GOOD CONDITION--- .-_--_.- ----
6. System Pumped By:
JAMES H CURRIER II H7_9 406_-_ ----___-----
Name
— --- — Vehicle License Number
X SEPTIC& DRAIN__---_-_.___.—.-_---
Campany
7. Location where contents were disposed:
GLS D ------------------—----- -------- ---
3/19/16 - -------------
---- ------
---
Date
Signature---
Signature of Receiving Facility(or attach facility receipt) Date
System Pumping Record•Page 1 of 1
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