HomeMy WebLinkAboutSeptic Pumping Slip - 115 JOHNNY CAKE STREET 8/30/2017Important: 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 De ised, but the
information must be substantially the same as that provided here. Before using this `orm, 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:
115 JOHNNY CAKE STREET
Address
NORTH ANDOVER MA
State
City/Town
2. System Owner:
RICHARD SINCERBEAUX
Name
01845
Zip Code
Address (if different from location)
City/Town
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
3. Component:
8/17/15
Date
2. Quantity Pumped:
❑ Cesspool(s) ® Septic Tank
❑ Other (describe):
1500
Gallons
❑ Tight Tank ❑ Grease Trap
4. Effluent Tee Filter present? ❑ Yes ❑ 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 dr
If yes, was it cleaned? ❑ Yes ❑ No
H79 406
Vehicle license Number
tea
Signature of Hauler
Signature of Receiving Facility (or attach facility receipt)
8/17/15
Date
Date
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