HomeMy WebLinkAboutSeptic Pumping Slip - 480 REA STREET 8/16/2016 Corns onwealth of Massachusetts RECEIVED
Cis /Town of NORTH ANDOVER
o
Sys
Pumping Record
Fora "����kk,,p� aryl u� Yc��.ia�1 wgrp� ��x�:w°�p
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 C3ca rd 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.
. rv,,, IMty Information -
Important:When
filling out forms 1. Sy-stem Location:
on the computer,
use only the tab 4810 REA ST
key to move your Addruss
cursor-do not NG1-v"'''6-I ANDOVER MA 01845
use the return _.._._ ...__.-- __..
key. City/Down State Zip Code
2. System Owner:
r� JILL ROMANO
Nexin
Ceram
Acldn'ss(if different from location)
City/Town State Zip Code
...
Telephone Number
B. �,j in Record
8/16/16 1500
1. D"( e, of Pumping Date ... .... 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) ® Septic Tank ❑ Tight Tank ❑ Grease Trap
El ether(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Cb: -rved condition of component pumped:
GOOD CONDITION
6. Sys fern Pumped By:
—,,,,'IES H CURRIER 11 H79 406
Warn,, Vehicle License Number
J` w;�:'PTIC & DRAIN
C€rrcrla;truy
7. Lo(:-.ition when,contents were disposed:
8/16/16...... .
SicgnE�trire of Hauler date
S'e�aatr�re of Receiving Facility(or attach facility receipt) hate
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