HomeMy WebLinkAboutSeptic Pumping Slip - 20 ROCKY BROOK ROAD 4/7/2016 Commonwealth of Massachusetts —IF
- City/Town of NORTH ANDOVER
ON
System in g Recor
Form 4 1"0014 CN: N O a t1 ANDOVER
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,
use only the tab 20 ROCKYBROOK ROAD
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
use the return -- - ------ --
------------ --
key. City/Town State Zip Cade
2. System Owner:
r� RALPH SAUIEGH
Name
rel�n
Address(if different from location)
---- ------ --- - -
City/Town State Zip Cade
------- -------- ------- -------
Telephone Number
B. Pumping Record
1. Date of Pumping 5/8/14 —_— 2 Quantity Pumped: 1500
Date Gallons
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 11 H79 406
Name Vehicle License Number
S SEPTIC & DRAIN
Company
7. Location where contents were disposed:
GLSD
. 5/8/14
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record-Page 1 of 1
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System Puny)htg Record
System Owner & Address:
Marie & Raouf Sayegh
20 Rocky Brook Road
North Andover, MA 01845
Location of system: Rear yard
Date of Pumping: October 24.2012
Type of system: Septic Tanlc.
Gallons Pumped: 1.500 gallons
System pumped by:
Service Pumping & Drain Co,, Inc.
S Hallberg Park
North Reading, Ma
License#: BHP-2011-041.3,0412,0411,0410,0409,0408
Contents transferred to: Greater Lawrence Sanitary District
Date: October 24, 2012 Pumping Technician: PK
This is PROPRIETARY and CONFIDENTIAL information that may
be used only by the Board of Health for regulatory purposes