HomeMy WebLinkAboutSeptic Pumping Slip - 107 LIBERTY STREET 12/4/2017 Commonwealth of Massachusetts RECEIVED
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City/Town of NORTH ANDOVER
System Pumping Record AMMR
EN f
H EALT -11 PMI M
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
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab .107 LIBERTY STREET
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
use the return
key. City/Town State Zip Code
2. System Owner:
LUIS CARRILLO
Name
/6f NR
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Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 11/14/17 2. Quantity Pumped: .1500
ate ballons
3. Component: F-1 Cesspool(s) E Septic Tank Ej Tight Tank El Grease Trap
F] Other(describe): .............
4. Effluent Tee Filter prr—,ont? as No If yes, was it cleaned? El Yes M No
5. Observed condition of component pumped:
GOOD
6. System Pumped By:
JAY CURRIER H79406
"Name Vehicle License Number
J'S SEPTIC & DRAIN
Company
7. Location where contents were disposed:
GLSD
11/14/17
g 6 a Date
.............
Signature of Receiving Facility(or attach facility receipt) Date
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