HomeMy WebLinkAboutSeptic Pumping Slip - 272 BRIDGES LANE 5/7/2018 Commonwealth of Massachusetts
011,
EC"EIVED
City/Town of NORTH ANDOVER R
System Pumping Record MAY 0 7 2018
Form 4
TOWN Or NOR,114 MDOVER
"A )
im���LD,11�u)AFU'MENT
DEP has provided this form for use by local Boards of Health. Other for may e 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 272 BRIDGES LANE
key to move your Address
cursor-do not NORTH ANDOVER MA01845
use the return —------- -------------
key. City/Town State Zip Code
VQ 2. System Owner:
LINDA HIBBS
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
4/23/181875
1. Date of Pumping 2Date . Quantity Pumped: Gallo,n-s.
3. Component: F-1 Cesspool(s) E Septic Tank F-1 Tight Tank 0 Grease Trap
n Other(describe):
4. Effluent Tee Filter present? E] Yes Ej No If yes, was it cleaned? ❑ Yes R No
5, Observed condition of component pumped:
GOOD
6. System Pumped By:
JAY CURRIER H79406
Name Vehicle License Number
J'S SEPTIC & DRAIN
d�impa-n"y----
7. Location where contents were disposed:
GLSD
4/23118
Sigr6ture of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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