HomeMy WebLinkAboutSeptic Pumping Slip - 2350 TURNPIKE STREET 8/30/2017Important: When
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tth
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
accordance with 310 CMR 15.351.
A. Facility Information
System Location:
2350 TURNPIKE ST
Address
NORTH ANDOVER
CityfTown
2. System Owner:
SCP CO.
MA
State
Name
Address (if different from location)
City/Town
01845
Zip Code
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
3. Component:
El Other (describe):
8/21/17
Date
Cesspool(s)
4. Effluent Tee Filter present?
1500
2. Quantity Pumped: Gallons
Septic Tank LJ Tight Tank 1:1 Grease Trap
Yes El No If yes, was it cleaned? 61 Yes [1] 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
e„,
Signature of Hauler
Signature of Receiving Facility (or attach facility receipt)
8/21/17
Date
Date
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