HomeMy WebLinkAboutSeptic Pumping Slip - 289 STILES STREET 12/21/2017 ' „,G11
un
Commonwealth of Massachusetts
r City/Town of NORTH ANDOVER
Pumping
0 l f A N�
� n tem s pin Record
dVEpLTH DiTIAYMI-IMI"
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 t
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 289 STYLES 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:
tak
MARY HOEHN
Name
/BIurA
Address(if different from location)
City/Town State Zip Code
Telephone Number -B. Pumping Record
1. Date of Pumping Date 17 2. Quantity Pumped: 2500
Date 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
i
6. System Pumped By:
JAY CURRIER H79406
_._ ._._.._._.___.._.___...._..._...__.____ ..._..._ ... ._..__. ___......_.__._ __.__.__.._ __.__.___.. .._.._.__._.___ _.
Name Vehicle license Number
J'S SEPTIC & DRAIN i
Company
I
7. Location where contents were disposed:
GLSD
12/11/17
Signature"of Hauler Date
i
Signa#ure of Receiving Facility(or attach facility receipt) Date
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