HomeMy WebLinkAboutSeptic Pumping Slip - 585 BOXFORD STREET 5/18/2017 Commonwealth of Massachusetts
1 '14 SID
City/Town of NORTH ANDOVER
StiK ystem uping Record
Form 4
IC
DEP has provided this form for use by local Boards of Health. Other formed, but the
information must be substantially the same as that provided here. Before�Zsi*nhlis 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 585 BOXFORD STREET
key to move your Address
cursor-do not NORTHANDOVERMA 01845
use the return
key. CitylTown State Zip Code
VQ 2. System Owner:
CHARLES BROGAN
............
Name
mtn
--------------- . .....
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Da 17-te--- 1500
— 2. Quantity Pumped: Gallons
3. Component: El Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
El Other(describe): —----------
4. Effluent Tee Filter present? r-1 Yes El No If yes, was it cleaned? El Yes El No
5. Observed condition of component pumped:
GOOD CONDITION
..........
& System Pumped By:
JAMES H CURRIER 11 H79 406
Name Vehicle License Number
XSEPTIC & DRAIN
Company
7. Location where contents were disposed:
GLSD
5/9/17
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc-11/12 System Pumping Record-Page 1 o€1