HomeMy WebLinkAboutSeptic Pumping Slip - 1459 TURNPIKE STREET 7/31/2017Important: 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:
1459 TURNPIKE ST
Address
NORTH ANDOVER MA 01845
City/Town State Zip Code
2. System Owner:
AYON CHOUDBURY
Name
Address (if different from location)
City/Town
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
3. Component:
El Other (describe):
7/25/17
Date
Cesspool(s)
2. Quantity Pumped:
1200
Gallons
Septic Tank 111 Tight Tank El Grease Trap
4. Effluent Tee Filter present? El Yes 111 No
5. Observed condition of component pumped:
GOOD
6. System Pumped By:
JAY CURRIER
Name
J'S SEPTIC & DRAIN
If yes, was it cleaned? 11 Yes 111 No
Company
7. Location where contents were disposed:
G LSD
H79406
Vehicle License Number
Signature of Hauler
Signature of Receiving Facility (or attach facility receipt)
7/25/17
Date
Date
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