HomeMy WebLinkAboutSeptic Pumping Slip - 101 DUNCAN DRIVE 6/7/2017Important: When
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Commonwealth 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
1. System Location:
101 DUNCAN DRIVE
Address
NORTH ANDOVER
City/Town
2, System Owner:
RALPH D'ATTARE
Name
Address (if different from location)
City/Town
MA
State
01845
Zip Code
State
Telephone Number
B. Pumping Record
1. Date of Pumping
3. Component:
5/17/17
Date
LI Cesspool(s)
0 Other (describe):
4. Effluent Tee Filter present? El Yes 0 No
5. Observed condition of component pumped:
GOOD CONDITION
6. System Pumped By:
JAMES H CURRIER II
Name
J' SEPTIC & DRAIN
Company
7. Location where contents were disposed:
GLSD
Signature of Hauler
2. Quantity Pumped:
1500
Gallons
Septic Tank 0 Tight Tank 0 Grease Trap
If yes, was it cleaned? 0 Yes El No
H79 406
Vehicle License Number
Signature of Receiving Facility (or attach facility receipt)
5/17/17
Date
Date
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