HomeMy WebLinkAboutSeptic Pumping Slip - 75 WINDSOR LANE 6/28/2017 Commonwealth of Massachusetts RECEIVED
City/Town of NORTH ANDOVER
JUL 0 5 M
System Pumping Record YOWN OF NORTH ANDOVER
Form 4 HEALTH DEPARTMENT
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. System Location:
on the computer,
use only the tab 75 WINDSOR LANE
............ ...
key to move your Address ......
cursor-do not NORTH ANDOVER MA 01845
use the return C
key. ityfTown State Zip Code
VQ 2. System Owner:
MAX PALLADINO
-----------
Name
retwn
Address-Cif different from-location)
_
City/TownState Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 6/28/17 2. Quantity Pumped: 1500
bifl�'_ -6-a-llo Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
Ej Other(describe):
4. Effluent Tee Filter present? ED Yes No If yes, was it cleaned? 0 Yes No
5. Observed condition of component pumped:
GOOD
6. System Pumped By:
JAY CURRIER H79406
Name Vehicle License Number -
J'S SEPTIC & DRAIN
c6n�i3an_y_
7. Location where contents were disposed:
GLSD
—------------
6/28/17
Signature of Hauler Date
S719_6iiur'e' o–f—Re—celving---Facility-_(or"attach--facility receipt) Dat..e
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