HomeMy WebLinkAboutSeptic Pumping Slip - 1689 SALEM STREET 11/23/2016 �
Commonwealth of Massachusetts
City/Town
��
^^/ NORTH ANDOVER
System Pumping Record
Form 4
-- DEP has provided this form for uso local Boards of Health. Other forms n)@ybe used, but the
inf0nn8tinnmumtb�oubnt�nUa||yth-' ann���thotprovid�dh�na� �afonsu�in0th|efo[m. Cheuhvvithyour
|noa| Board ofHea|thho determine -fo[nO they use. The System Pumping Record nnuethe submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in �
accordance with 31OCK4R15.351.
Important:When A. Facility Information Recelveo
filling out forms 1. Synban« Location: 8L/` U �� ���A
on�oo*mpu�� ��,�
�TREET
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use the return -----------�-----Ity s�State upv""�
own
key.
2. System Owner:
'
RKSHEA
moma
Address(if different from location)
State Zip Code
Telephone Number
Ody�uwo
1500
1 Date 11/23/1� 2. Quantity Pumped: GaUona
' ueoe
3. Component: El (|meapooKa) Z Septic Tank [� Tight Tank [l Grease Trap
El Other(describe):
4. Effluent Tee Filter present? Z Yes F-1 No |f yes, was itcleaned? Z Yea || No
5. Observed condition of component pumped:
'
GOOD CONDITION
| 6. System Pumped By:
JAMES H CURRIER || H79 408
Name License Number
� XSEPTIC & DRAIN
Company
� 7. Location where contents were disposed:
GLSD
� . 23 .
Date
Signature
Signature of Receiving Facility(or attach facility receipt) Date
Syetem Pumping Record`Page 1of1
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