HomeMy WebLinkAboutSeptic Pumping Slip - 273 BERRY STREET 12/21/2017 _< Commonwealth of Massachusetts
r City/Town of NORTH ANDOVER
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t u pin Record
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_ WI i 'i'i
Form 4 f
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, 2
use only the tab 73 BERRY STREET
key to move your Address
cursor-do not NORTH ANDOVERMA 01845
use the return _ .......___ _ __..... _ _.._._._
key. City/Town State Zip Code
2. System Owner:
rab JOSH SEIDEL
. ... w_....._._
Name
reran w
Address(if different from location)
Cityfrown State Zip Code
Telephone Number
B. Pumping Record -
1. Date of Pumping Date12/15/17 2. Quantity Pumped: 1500
Gallons
3. Component: ❑ Cesspool(s) ® Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): PUMP CHAMBER- REPAIRS
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
J'S SEPTIC & DRAIN
Company
7. Location where contents were disposed:
GLSD
12/15/17
Sfgfiature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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