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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 t5form4.doc•11/12 System Pumping Record•Page 1 of 1