HomeMy WebLinkAboutSeptic Pumping Slip - 1459 TURNPIKE STREET 7/12/2016 Commonwealth of Massachusetts
City/Town of NORTH ANDOVER
System Pumping Record
- Form
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 t , r In
accordance with 310 CMR 15.351.
A. Facility Information
Important:When 1�p"7P 4 F i CRH" AP��DOV���F7,
filling out forms 1. System Location: (14 ALX� # I.I'a�I l"V� IqT
on the computer, 1459 TURNPIKE ST
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:
r� AYAN CHOUDHURY
Name
�enrn
Address(if different from location)
--- ------- — - --------- — — ------
City/Town State Zip Code
----- ----- - -------- -
Telephone Number
B. Pumping Record
1. Date of Pumping 7/12/16 — 2. Quantity Pumped: 1000- -----
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:
GLSDf
7/12/16
Signature of Hauler Date
— -- -- -------
Signature of Receiving Facility(or attach facility receipt) Date
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