HomeMy WebLinkAboutSeptic Pumping Slip - 125 JOHNNY CAKE STREET 11/8/2017 Commonwealth of Massachusetts
_ .0 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 Y
Important:When
filling out forms 1. System Location:
on the computer, 125 JOHNNY CAKE
use only the tab
key to move your Address
cursor-do not NORTH ANDOVERMA 01845
use the return
use State Zip Code
2. System Owner:
r MARK WEBSTER____
Name
re2an
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
10/31/17 1500
1. Date of Pumping Date 2. Quantity Pumped: Gallons _....._..
3. Component: ❑ Cesspool(s) ® Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? Yes [2 No If yes, was it cleaned? . Yes ! 1 No
5. Observed condition of component pumped:
GOOD
6. System Pumped By:
JAY CURRIERH79406
_ . ..__... _m.__....,.. _._...___... ..___._..----------
Name
__-___._Name Vehicle License Number
J'S SEPTIC & DRAIN
Company
7. Location where contents were disposed:
GLSD
10/31/17
Signatur6 of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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