HomeMy WebLinkAbout- Septic Pumping Slip - 110 BROOKVIEW DRIVE 9/4/2018 Commonwealth of Massachusetts [.'E,,, CE1VED
City/Town of NORTH ANDOVER
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TOWN OF�10RJHANDOVER
System Pumping Record
Form 4 Fff,,N TI J�I i10EN'r
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 110 BROOKVI EW DRIVE
key to move your Address
cursor-do not NORTH ANDOVERMA 01845
use the return ---
key. City/Town State Zip Code
2. System Owner:
riaBOB SWEENEY
,Name
renrn
-Add location)
.6i0ow.n State Zip I Code
.................
Telephone Number
B. Pumping Record
1. Date of Pumping 8/24/18 2. Quantity Pumped: 1500
Date Gallons
3. Component: ❑ Cesspool(s) Z Septic Tank 0 Tight Tank F] Grease Trap
El Other(describe):
4. Effluent Tee Filter present? F Yes Ej No If yes, was it cleaned? E] Yes 0 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
.............................
8/24/18
Signature of Hauler Date
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Signature--o—f--Receiving—Facilityattach facility receipt) Date
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