HomeMy WebLinkAboutSeptic Pumping Slip - 20 ROCKY BROOK ROAD 5/14/2018 Commonwealth of Massachusetts
RECEIVED
City/Town of NORTH ANDOVER
System Pumping Record MAY 14 ?018
0 Form 4 OW14 OF NOR1 F1 ANDOVM
Yd
J,JEALRi LUMTMEN'r
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,
use only the tab .20 ROCKYBROOK RD ....................
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
use the return
key. City/Town State Zip Code
2. System Owner:
-RALPH SAUEIGH .............. ........
Name
renin
---------
Address(if different from location)
............. ----------------
City/Town State Zip Code
'Telephone Number
_.......... -... --------- - — —.
B.
unber ----------
B. Pumping Record
1500
1. Date of Pumping 5/8/18 ........................... 2Date . Quantity Pumped: Gallons
1 Component: ❑ Cesspool(s) E Septic Tank El Tight Tank n Grease Trap
F-1 Other(describe):
4. Effluent Tee Filter present? El Yes Ej No If yes, was it cleaned? [:1 Yes E] 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
5/8/18
Signature of Fia–ul—er Date
...............
Signature of Receiving Facility(or attach facility receipt) Date
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