HomeMy WebLinkAboutSeptic Pumping Slip - 76 BOSTON HILL ROAD 3/25/2016 Commonwealth of Massachusetts
F City/Town of NORTH ANDOVER
System pumping Record
Form 4
^ P has provided this form for use by local Boards of Health. Other forms may be used; but the
D
information must be substantially the same as that provided here. Pufm en this form,
d must�e your
local Board of Health to determine the form they use. The System Pumping ,irt date in
the local Board of Health or other approving authority within 14 days from the pumping
accordance with 310 CMR 15.351,
A. Facility Information
Important:When 1 System Location:
filling out forms y
on the computer, 76 BOSTON HILL ROAD
use only the tab Address 01845
key to move your MA
cursor-do not NORTH ANDOVER State Zip Code
use the return City/Town
key.
2. System Owner:
t� KEVIN DUBE
Name
renrn
Address(if different from location)
State Zip ode
C
City/Town
Telephone Number
B. pumping Record 1500
3/25/16 2. Quantity Pumped: Gallons
1. Date of Pumping Date
Septic Tank Se F] Tight Tank ❑ Grease Trap
3. Component: ❑ Cesspool(s) ® p
❑ Other(describe):
If es, was it cleaned? ® Yes ❑ No
4. Effluent Tee Filter present? ® Yes ❑ No Y
5. Observed condition of component pumped:
GOOD CONDITION
6. System Pumped By:
H79 406
JAMES H CURRIER II Vehicle License Number
Name
X SEPTIC & DRAIN
Company
7. Location where contents were disposed:
GLSD
3/25/16
Date
Signature of Hauler
Signature of Receiving Facility(or attach facility receipt)
Date
System Pumping Record•Page 1 of 1
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