HomeMy WebLinkAboutSeptic Pumping Slip - 2370 TURNPIKE STREET 8/30/2017Important: When
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Commonwealth of Massachusetts
City/Town of NORTH ANDOVER
System Pumping Record
Form 4
',1)
10
DEP has provided this form for use by local Boards of Health. Other forms may bekt1Te-d, 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:
2370 TURNPIKE ST
Address
NORTH ANDOVER
City/Town
2. System Owner:
J.C. FENCE CO.
Name
Address (if different from location)
City/Town
MA
State
01845
Zip Code
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
3. Component:
8/21/17
Date
[1] Cesspool(s)
Ej Other (describe):
2. Quantity Pumped:
1500
Gallons
Septic Tank Lil Tight Tank [1] Grease Trap
4. Effluent Tee Filter present?
r4
Yes 111 No
5. Observed condition of component pumped:
GOOD
6. System Pumped By:
JAY CURRIER
Name
J'S SEPTIC & DRAIN
Company
7. Location where contents were disposed:
GLSD
Signature of Hauler
If yes, was it cleaned? Yes Ci No
Signature of Receiving Facility (or attach
acility receip
H79406
Vehicle License Number
8/21/17
Date
Date
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