HomeMy WebLinkAboutSeptic Pumping Slip - 1423 SALEM STREET 5/18/2017 Commonwealth of Massachusetts 0,0s4so
I P-le I,
CTown of NORTH ANDOVER
System Pumping Record
Form 4 �,`�Aj
DEP has provided this form for use by local Boards of Health. Other forms 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,
use only the tab 1423 SALEM STREET
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
use the return .......
key. City/Town State Zip Code
WGI 2. System Owner:
COURTNEY SCRUGGS
Name
ratan
.Add,r I e-s-s-(if different from location) —-----
CityfTown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 17 2. Quantity Pumped: 150llo0
Date Gans
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
Fj Other(describe): ------------
4. Effluent Tee Filter present? n Yes E] No If yes, was it cleaned? n Yes F] No
5. Observed condition of component pumped:
GOOD CONDITION
6. System Pumped By:
.JAMES H CURRIER If H79 406
Name Vehicle License--
J` SEPTIC & DRAIN
Company
7. Location where contents were disposed:
GLSD
5/1/17
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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