HomeMy WebLinkAboutSeptic Pumping Slip - 158 OLYMPIC LANE 10/2/2017Important: When
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Commonwealth of Massachusetts
City/Town of NORTH ANDOVER
System Pumping Record
Form 4
OCS 2- 7°
714 NI`lDE
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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:
158 OLYMPIC LANE
Address
NORTH ANDOVER MA
State
City/Town
2. System Owner:
VERONICA CAMIRE
Name
Address (if different from location)
City/Town
State
01845
Zip Code
Telephone Number
Zip Code
B. Pumping Record
9/26/17
1. Date of Pumping 2. Quantity Pumped:
Date
1200
Gallons
3. Component: 11 Cesspool(s) Septic Tank 0 Tight Tank D Grease Trap
0 Other (describe):
4. Effluent Tee Filter present? Lil Yes El 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? El Yes 0 No
H79406
Vehicle License Number
9/26/17
Date
Signature of Receiving Facility (or attach facility receipt) Date
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