HomeMy WebLinkAboutSeptic Pumping Slip - 478 BOSTON STREET 6/20/2016 Commonwealth Of Massachusetts
City/Town Of NORTH ANDOVER
- 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 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:
an the computer, �f,IL�s"r'����:r�t
use only the tab 478 BOSTON ST .--.__.__-._..---------...- ��C---
key to move your Address 01845
cursor-do not NORTH ANDOVER - -- -------- ----
—--— ----..._ State Zip Code
use the return City/'rown
key.
2. System Owner:
tab
SEAN MERRIAIN --_----
Name
znrn _
Address(if different from location)
—..------ -- --
State Zip Code
------- —__
City/Town
Telephone Number
B. Pumping rd
6/20/1.6 1500__ -----
1. Date of Pumping ------- 2. Quantity Pumped: Gallons
Date
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:
GOO D CON DITI O N --.---____---..----..----- -- -- -
6. System Pumped By:
JAMES H CURRIER LI H79 406 __ ---
------.— _——— — ---------- —-- Vehicle License Number
Name
X SEPTIC & DRAIN - -------.--.-._.
Company
7. Location where contents were disposed:
GLSD
----------
�� 6420/16
Date
Signature of Hauler
Signature of Receiving Facility(or attach facility receipt) a
System Pumping Record•Page 1 of 1
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