HomeMy WebLinkAboutSeptic Pumping Slip - 1365 SALEM STREET 10/25/2017Commonwealth of Massachusetts
City/Town of NORTH ANDOVER
System Pumping Record
Form 4
OCT 25 201/
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
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. System Location:
on the computer,
use only the tab 1365 SALEM ST
key to move your Address
cursor - do not NORTH ANDOVER MA 01845
use the return
key City/Town State Zip Code
2. System Owner:
HELEN CUNNIFF
Name
Address (if different from location)
City/Town
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
10/23/17 15000
2. Quantity Pumped:
Date
Gallons
3. Component: Lil Cesspool(s) Septic Tank El Tight Tank 0 Grease Trap
01 Other (describe):
4. Effluent Tee Filter present? CI Yes 0 No If yes, was it cleaned? 11] 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
H79406
Vehicle License Number
10/23/17
Signature of Hauler Date
Signature of Receiving Facility (or attach facility receipt) Date
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