HomeMy WebLinkAboutSeptic Pumping Slip - 480 REA STREET 8/1/2018 ,�L\- Commonwealth of Massachusetts
...... RECEIVED
City/Town of NORTH ANDOVER
System Pumping Record
_ ❑ Form 4 OWN 0i: A,�jt)(WER
DEPI�PTME141'
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 480 REA ST
key to move your Address
cursor-do not NORTH ANDOVERMA 01845
use the return
key. City[Town State Zip Code
2. System Owner:
VQ ALLROMANO
Name
Address(if different from location)
City/Town State Zip Code
'Telephone Number
B. Pumping Record
6/29/18 1500
1. Date of Pumping bate 2. Quantity Pumped: -daj'(6.n I s.............
3. Component: El Cesspool(s) Z Septic Tank El Tight Tank Grease Trap
n Other(describe):
4. Effluent Tee Filter present? F Yes El No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
GOOD
-—--------- —------
6. System Pumped By:
JAY CURRIER H79406
Name Vehicle License Number
J'S SEPTIC
EPTIC & DRAIN
- . ....66mpany
7. Location where contents were disposed:
GLSD
6/29/18
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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