HomeMy WebLinkAboutSeptic Pumping Slip - 272 BRIDGES LANE 4/18/2017Commonwealth of Massachusetts
City/Town of NORTH ANDOVER
System Pumping Record
Form 4
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 pit ng date in
accordance with 310 CMR 15.351.
A. Facility Information
Important: When
filling out forms 1.
on the computer,
use only the tab
key to move your
cursor - do not
use the return
key.
rnb
System Location:
272 BRIDGES LANE
\c-1\ •
Address
NORTH ANDOVER MA
State
City/Town
2. System Owner:
LINDA HIBBS
Name
Address (iiCifierent from location)
City/Town State
Telephone Number
01845
Zip Code
Zip Code
B. Pumping Record
1. Date of Pumping
3. Component:
0 Other (describe):
4/17/17
Date
Cesspool(s)
2. Quantity Pumped:
1500
Gallons
Septic Tank 0 Tight Tank El Grease Trap
4. Effluent Tee Filter present? 0 Yes 0 No
5. Observed condition of component pumped:
GOOD CONDITION
If yes, was it cleaned? 0 Yes 0 No
6. System Pumped By:
JAMES H CURRIER II
Name
J' SEPTIC & DRAIN
Company
7. Location where contents were disposed:
GLSD
Signature of Hauler
Signature of Receiving Facility (or attach facility receipt)
H79 406
Vehicle License Number
4/17/17
Date
Date
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