HomeMy WebLinkAboutSeptic Pumping Slip - 20 ROCKY BROOK ROAD 5/9/2016 f Commonwealth Of Massachusetts
u� City/Town Of NORTH ANDOVER
- "
System u i Record
Farm 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 pumping date in
accordance with 310 CIVIR 15.351. RECEIVED
A. Facility Information
Important:When
filling out forms 1. System Location: ( I.? li dIt:y l" "
on the computer,
20 ROCKY BROOK LANE -.....-- -. .._......_...__ t°�EN...'1 kP�P����ml�
use only the tab _
---........-------
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
use the return ..
key. City/Town State Zip Code
2. System Owner:
tab
RALPH SAUEIGH
Name
retr�n
Address(if different from location)
----------- ---------- --
City/Town State Zip Code
Telephone Number
B. Pumping ecor
1. Date of Pumping 5/9/16 -----...-- 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 II H79 406
---- _.. --- -- --- --- -- - --- -- -......--------
Name Vehicle License Number
J' SEPTIC & DRAIN
Company
7. Location where contents were disposed:
GLSD r%1'
m
5/9/16
Signature of Hauler Date
- ----- ..... .. -- - - - -- -
Signature of Receiving Facility(or attach facility receipt) Date
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