HomeMy WebLinkAboutSeptic Pumping Slip - 1050 FOREST STREET 5/7/2018 Commonwealth of Massachusetts
City/Town of NORTH ANDOVER
System Pumping Record
Form 4 tA 0 t4c)P0 'N�
DEP has provided this form for use by local Boards of Health. Other fort 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 1050 FOREST ST
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
use the return -__.___'--------
key. City/Town State Zip Code
ren
2. System Owner:
DONNA CABRAL
-—---_---------------------
Name _
ietuxn
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 4/18/18 2. Quantity Pumped: 1500
Date Gallons
3. Component: Fj Cesspool(s) E Septic Tank F] Tight Tank ❑ Grease Trap
F] Other(describe):
4. Effluent Tee Filter present? F-1 Yes Ej No If yes, was it cleaned? Ej Yes El 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
4/18/18
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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