HomeMy WebLinkAboutSeptic Pumping Slip - 83 CAMPBELL ROAD 5/23/2016 Commonwealth Of Massachusetts
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City/Town Of NORTH ANDOVER
System Pumping Recr
Form 4
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 mping date in
accordance with 310 CMR 15.351.
A. Facility Information �4��
filling When
g outfoms 1. System Location: 1 k0V-
on the computer, J �
use only the tab 83 CAMPBELL ROAD
-
key to move your Address ---------- —----
----
cursor-do not NORTH ANDOVER MA 01845
usethe return . __............. -----_..__.....-------._ ---------
key.
City/Town State Zip Code
2. System Owner:
LUCY FALLON
... -- ---
Name
eam
Address(if different from location)
--
---------- —...-.. _.....- ----------------------
-- ---..._
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 5 Da te.t.e. - 2. Quantity Pumped: 12Q —
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 II H79 406
Name Vehicle License Number
X SEPTIC & DRAIN
_.. --....----
Company
7. Location where contents were disposed:
GLSD _..._.._
5/6/16
Signature of Hauler Date
......------ --------------------
Signature of Receiving Facility(or attach facility receipt) Date
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