HomeMy WebLinkAboutSeptic Pumping Slip - 80 BOSTON 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:
80 BOSTON STREET
Address
NORTH ANDOVER MA
State
City/Town
2. System Owner:
THE SPOT
01845
Zip Code
Name
Address (if different from location)
City/Town
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
3. Component:
7/11/17
Date
Lil Cesspool(s)
111 Other (describe):
2. Quantity Pumped:
1500
Gallons
Septic Tank 0 Tight Tank EI Grease Trap
4. Effluent Tee Filter present? Yes D No
5. Observed condition of component pumped:
GOOD
If yes, was it cleaned? 2 Yes El No
6. System Pumped By:
JAY CURRIER
Name
J'S SEPTIC & DRAIN
Company
7. Location where contents were disposed:
GLSD
6,16c
Signature of Hauler
H79406
Vehicle License Number
Signature of Receiving Facility (or attach facility receipt)
7/11/17
Date
Date
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