HomeMy WebLinkAboutSeptic Pumping Slip - 227 GRANVILLE LANE 6/6/2017 Commonwealth of Massachusetts RECEIVED
City/Town of NORTH ANDOVER
JUL 0 51
System Pumping Record
Form 4 TOWN OF NORTH ANDOVER
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 227 GRANDVILLE LANE
key to move your Address
cursor-do not NORTH ANDOVERMA 01845
use the return Cityrrown State Zip Code
key.
ren 2. System Owner:
JAKE CHACE
Name
..........
Address(if different from location)—-_
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping .6/6/17 2. Quantity Pumped: 1500
bi-W— Gallons
3. Component: El Cesspool(s) Z Septic Tank F-1 Tight Tank F-1 Grease Trap
R Other(describe): ____..............
4. Effluent Tee Filter present? n Yes n No If yes, was it cleaned? F] Yes R No
5. Observed condition of component pumped:
-GOOD ____..............
6. System Pumped By:
JAY CURRIER H79406
Name Vehicle License Number
J'S SEPTIC & DRAIN
Company
7. Location where contents were disposed:
GLSD
6/6/17
Signature of Hauler Date
—---------
ignature of Receiving Facility(or attach facility receipt) Date
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