HomeMy WebLinkAboutSeptic Pumping Slip - 160 CARLTON LANE 11/17/2017 Commonwealth of Massachusetts RECEIVED
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City/Town of NORTH ANDOVER
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System Pumping RecordTOWNOFNORTHANDOVER
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HEALTH DERA TIVii.�r+T
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:
an the computer,
use only the tab 160 CARLETON LANE
key to move your Address --.__--
cursor-donot NORTH ANDOVERMA 01845
use the return -
key. Cityfrown State Zip Code
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2. System Owner:
DARREN WINNIE
_ _ __.
Name
iatrn
Address(if different from location)
Cityfrawn State Zip Code
Telephone Number
B. (Pumping Record
11/6/17 1500
1. Date of Pumping gate -- 2. Quantity Pumped: -Gallons
3. Component: ❑ Cesspool(s) ® Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): .-__._
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
GOOD
6. System Pumped By:
JAY CURRIER H79406
Name Vehicle License Number
TS SEPTIC & DRAIN
Company
7. Location where contents were disposed:
GLSD
r 11/6/17
Signgtufe of Hauler Date
_......................_..... ------ ---
Signature of Receiving Facility(or attach facility receipt) Date
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