HomeMy WebLinkAboutSeptic Pumping Slip - 2200 TURNPIKE STREET 10/26/2016 Commonwealth of Massachusetts RECEIVED
City/Town Of NORTH ANDOVER
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Form 4 T N OF N RIHAN)OV R
t°IFALTH DEPAFUMENT
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 r ti® -
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 2200 TURNPIKE ST.
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
use the return
key. City/Town State Zip Code
2. System Owner:
xb LARRY TRACEY
Name
E
Address(if different from location)
___ .. _.- ------- — -- —
City/Town State Zip Code
- - --...
Telephone Number
B. Pumping Record
10/26/16 1000
1. Date of Pumping --_._-__. 2. Quantity Pumped:
Date Gallons
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 H79 406
Name Vehicle License Number
X SEPTIC & DRAIN
Company
7. Location where contents were disposed:
GLSD
10/26/16
-- -- ._....
Signature of Hauler Date
------ ----— —..._-,....
Signature of Receiving Facility(or attach facility receipt) Date
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