HomeMy WebLinkAboutSeptic Pumping Slip - 90 CAMPBELL ROAD 11/17/2017 1111. _ Commonwealth of Massachusetts RECEIVED RECEIVED
City/Town of NORTH ANDOVER
System Pumping Record 'TOWN OF fl]AWGV,"i"'k
Form 4
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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
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab ..9.0 ................ ..........
..................................
key to move your Address
cursor-do not NORTH ANDOVERMA 01845
use the return City/Town "S6te ......... Zip Code
key.
2. System Owner:
MARY PENNEY
Name
Address(if different from location)
----------—-----
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping ate 11/13/17 2. Quantity Pumped: 1500
Gallons
3. Component: El Cesspool(s) M Septic Tank Tight Tank [:1 Grease Trap
El Other(describe): ....................-11 1-1---- -........................
4. Effluent Tee Filter present? F1 YeSEI No If yes, was it cleaned? F-1 Yes F] No
5. Observed condition of component pumped:
GOOD
------11................- ...........I..........
6. System Pumped By:
-JAY CURRIER ........... �H79406
Name Vehicle License Number—
TS SEPTIC & DRAIN
.Com-pany
7. Location where contents were disposed:
GLSD
11/13/17
............ — 1111
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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