HomeMy WebLinkAboutSeptic Pumping Slip - 76 BOSTON HILL ROAD 5/18/2017Commonwealth 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 pumping 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.
CityfTown
2. System Owner:
KEVIN DUBE
System Location:
76 BOSTON HILL ROAD
Address
NORTH ANDOVER MA
State
Name
Address (if different from location)
City/Town
01845
Zip Code
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
3. Component:
LI
0 Other (describe):
5/12/17
Date
Cesspool(s)
4. Effluent Tee Filter present?
Yes 11] No
5. Observed condition of component pumped:
GOOD CONDITION
6. System Pumped By:
JAMES H CURRIER II
Name
JSEPTIC & DRAIN
Company
2. Quantity Pumped:
1500
Gallons
Septic Tank fl Tight Tank 0 Grease Trap
7. Location where contents were disposed:
GLSD
-
Signature of Hauler
If yes, was it cleaned? Yes 0 No
H79 406
Vehicle License Number
Signature of Receiving Facility (or attach facility receipt)
5/12/17
Date
Date
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