HomeMy WebLinkAboutSeptic Pumping Slip - 308 CAMPBELL ROAD 8/9/2018 �LN Commonwealth of Massachusetts RECEIVED
City/Town of NORTH ANDOVER N
System Pumping Record TOWN OF NORTF�ANDOVER
Form 4 KAI.11i DEPARTMENT
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 308 CAMPBELL RD
key to move your Address
cursor-do not NORTH ANDOVERMA 01845
key.
use the return Cityl-rown State Zip Code
00 2. System Owner:
STEVE TESSLER
Name
----------
Address-—(If different from location)
City/Town State Zip Code
Telephone- --lNumber--
B. Pumping Record
1. Date of Pumping 7/31/18 2. Quantity Pumped: 1500
Date da�llons
3. Component: F-1 Cesspool(s) Z Septic Tank F1 Tight Tank ❑ Grease Trap
F-1 Other(describe): .. .....
4. Effluent Tee Filter present? El Yes ❑ 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 & DRAIN
Company
7. Location where contents were disposed:
-GLSD -----------
7/31/18
------------
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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