HomeMy WebLinkAboutSeptic Pumping Slip - 1929 SALEM STREET 5/14/2018 Commonwealth of Massachusetts
City/Town of NORTH ANDOVER RECEIVED
System Pumping Record MAY 11
Form 4 VOW�j OF NORT�
[)j"j>AM MEW
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
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A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 1929 SALEM STREET
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
use the return ......
key. City/Town State Zip Code
VQ 2. System Owner:
MIGAURI RODRIGIZ
Name
enun
Address--(if-different-from location)
City/Town State Zip Cade
Telephone Number
B. Pumping Record
1. Date of Pumping 5/8/18 2. Quantity Pumped: 1500
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank n Tight Tank El Grease Trap
El Other(describe):
4. Effluent Tee Filter present? Yes ❑ No If yes, was it cleaned? Yes ❑ No
5. Observed condition of component pumped:
GOOD
6. System Pumped By:
JAYCURRIER H79406
.............
Name Vehicle License Number
-J'S SEPTIC & DRAIN ................................
Company
7. Location where contents were disposed:
GLSD
5/8/18
Signature of Hauler Date
..._..............
Signature of Receiving Facility(or attach facility receipt) Date
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