HomeMy WebLinkAboutSeptic Pumping Slip - 2350 TURNPIKE STREET 8/30/2017 (2)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
Important: When
filling out forms 1.
on the computer,
use only the tab
key to move your
cursor - do not
use the return
key.
System Location:
2350 TURNPIKE ST. BLDG C
Address
NORTH ANDOVER MA
State
City/Town
2. System Owner:
NO MID LLC
Name
Address (if different from location)
City/Town
01845
Zip Code
State Zip Code
Telephone Number
B. Pumping Record
1.
Date of Pumping
8/18/17
2. Quantity Pumped:
Date
3. Component: L Cesspool(s) [E] Septic Tank
El Other (describe):
4. Effluent Tee Filter present? 0 Yes 0 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
5000
Gallons
fl Tight Tank 0 Grease Trap
If yes, was it cleaned? 111 Yes 0 No
H79406
Vehicle License Number
Signature of Receiving Facility (or attach facility receipt)
8/18/17
Date
Date
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