HomeMy WebLinkAboutSeptic Pumping Slip - 272 BRIDGES LANE 5/18/2016 Commonwealth of Massachusetts
c� a City/ own of NORTH ANDOVER
I _ System Pumping Record
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 Pum i must be submitted to
the local Board of Health or other approving authority within 14 da ping date in
accordance with 310 CMR 15.351.
A. Facility Information wt Of NOR,��������,���.c
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 272 BRIDGES LANE
key to move your Address
cursor-do not NORTH ANDOVER MA 018_45
use the return - --- ---
key. City/Town State Zip Code --
%� 2. System Owner:
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LINDA HIBBS
Name --- - --
e wn
--------- - --
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
5/18/16 1500
1. Date of Pumping Date ------------------------------------ 2. Quantity Pumped: 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 ,%r
--- -
AXe—z a 5/18/16
Signature of Hauler Date
_...........- ------ -
Signature of Receiving Facility(or attach facility receipt) Date
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