HomeMy WebLinkAboutTitle V Inspection Report - 835 CHESTNUT STREET 3/11/2016 Commonwealth of Massachusetts CEIVED
N W City/Town 0f N. ANDOVER
System Pumping Record
'I" � i:NORTH ANDO�rE�?Farr 4
tEAi_TI4 CEPARTMENT
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, 835 CHESTNUT STREET
use only the tab _
key to move your Address
cursor-do not N. ANDOVER MA _01845
use the return City/Town State Zip Code
key.
2. System Owner:
DIANNA GAUDET
Name
return
Address(if different from location)
City/Town State Zip Code
978-857-8530
Telephone Number
B. Pumping cord
1. Date of Pumping 3/11/16 2. Quantity Pumped: 1500
Date Gallons
3. Component: ❑ Cesspool(s) ®' Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? V1 Yes ❑ No If yes, was it cleaned? 2 Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
JOHN SOUCY 7626 AR
Name Vehicle License Number
SOUCY SEPTIC SERVICE INC
Company
7. Location where contents were disposed:
G.L.S.D.
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1