HomeMy WebLinkAboutSeptic Pumping Slip - 2211 TURNPIKE STREET 7/2/2018 Commonwealth of Massachusetts REC!,'-:3,,kf ED
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Cityffown of NORTH ANDOVER
System Pumping Record
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Form 4g. 'J"'
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 2211 TURNPIKE STREET ....................... -----------
key to move your Address
cursor-do not NORTH ANDOVERMA 01845
use the return
key. City/Town State Zip Code
2. System Owner:
ESTATE OF RECARDO DEJESUS
Name
rerun
-Address(if different from to"cati-on-)..........
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City/Town State Zip Code
Tele hone Number
—--------- ..... -
B.
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B. Pumping Record
1. Date of Pumping 6/13/18 2. Quantity Pumped: 1500
Date Gallons
3. Component: F-1 Cesspool(s) M Septic Tank F-1 Tight Tank F] Grease Trap
n Other(describe): ......
4. Effluent Tee Filter present? F-1 YesEl No If yes, was it cleaned? 0 Yes F-1 No
5. Observed condition of component pumped:
.GOOD
6. System Pumped By:
JAY CURRIER H79406
Nam'— Vehicle License Number
J'S SEPTIC & DRAIN
Company---
7. Location where contents were disposed:
GLSD
6/13/18
Signature of Hauler Date
.............
Signature of Receiving Facility(or attach facility receipt) Date
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