HomeMy WebLinkAboutSeptic Pumping Slip - 108 LIBERTY STREET 6/3/2016 Commonwealth �� Massachusetts
���j����(���\�����/u / ��/ RECEIVED
City/Town of
System Pumping Record
Form 4 �Q�W�FNORTHAN0JVE�
HEAJM��R4RT�ENT
DEP has provided this form for use by local Boards of Health. Other forms may be uaed, but the
information must be substantially the same oethat provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must he submitted bo |
�
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 31OCMR15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 108 LIBERTY STREET
key m move your Address �
cursor-do not |
NORTH ANDOVER O1O45
use the�mm =" �
key.
Ci��own S�� Zip Code
2. System Owner: |
~---�'
PHIL QUINN �
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date ofPumping Date 2� Quantity Pumped: 1500
Gallons
3. Component El Cesspool(s) F� Septic Tank El Tight Tank 0 Grease Trap
0 Other(describe):
�
4. Effluent Tee Filter F-1 Yes n No If yes, was it cleaned? r-1 Yes El No �
5. Observed condition of component pumped: �
GOOD CONDITION
O. System Pumped By:
JAMES H CURRIER 11 H79 406
Name Vehicle License Number
J' SEPT|C & DRAIN
Company
7, Location where contents were disposed:
GLSD
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) oarm
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