HomeMy WebLinkAboutSeptic Pumping Slip - 1253 SALEM STREET 8/1/2018 Commonwealth of Massachusetts RECEIVED
City/Town of NORTH ANDOVER
System Pumping Record TOW t,OF tip,�,�
Form 4 HE,A"L f jj I) j-,ARTMUIT
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 1253 SALEM ST ......
key to move your Address
cursor-do not NORTH ANDOVERMA 01845
use the return
key, City/Town State Zip Code
ray 2. System Owner:
LINDA BRODETTE
'IN-an-e--
ensn
Ad&eii-(if different from—location)
-------------
CitylTawn
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 7/12/18 2. Quantity Pumped: 1500
DateGallons
3. Component: El Cesspool(s) Septic Tank F1 Tight Tank El Grease Trap
n Other(describe):
4. Effluent Tee Filter present? F YesEl No If yes, was it cleaned? F Yes 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 ............ .......... ..........
7/12/18
Signature of Hauler Date
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7Si6nature of Receiving Facility(or attach facility receipt) Date
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