HomeMy WebLinkAboutSeptic Pumping Slip - 1253 SALEM STREET 6/2/2016 Commonwealth of Massachusetts
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City/Town of NORTH ANDOVER RECEIVED
D
System Pumping Record
Form 4
r c yr)0y/D1
DEP has provided this form for use by local Boards of Health. Other forms mAvb 61 " ,"Ibullik'
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, 1253 - ____
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
use the return --------- —
key.
City/Town State Zip Code
2. System Owner:
r� LINDA BRODETTE
Name
endn
Address(if different from location)
— ._..._
City/Town State Zip Code
.........._.._.._------
Telephone Number
B. Pumping Record
1. Date of Pumping 5/2/16 2. Quantity Pumped: 1_5-00-_ --
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
X SEPTIC & DRAIN
-- ... - - -_--
Company
7. Location where contents were disposed:
GLSD
-� 6/2/16
Signature of Namlet.,w.. .�% � ;..,b Date
.. ........ -._
Signature of Receiving Facility(or attach facility receipt) Date
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