HomeMy WebLinkAboutSeptic Pumping Slip - 308 CAMPBELL ROAD 8/16/2016 -----------
Commonwealth of Massachusetts RECEIVED
City/Town of NORTH ANDOVER U G
w System Pumping Record .
'10WINI OF 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:
on the computer, 308 CAMPBELL RD
use only the tab ....__- .
key to move your Address ` _.....�
cursor-do not NORTH ANDOVER MA I
use the return
key. City/Town Stake Zip Code
2. System Owner:
f� STEVE TESSLER
Name
iaaun
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
8116116 1500
1. Date of Pumping Date — 2. Quantity Pumped: Gallons 4
3. Component: ❑ Cesspool(s) ® Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? El 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 _............ ..._._. H79406
Name Vehicle License Number
S SEPTIC & DRAIN
Company
7. Location where contents were disposed:
GLSD
8/16/16
Signature of Hauler date
_. .........__
Signature of Receiving Facility(or attach facility receipt) Date
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