HomeMy WebLinkAbout- Septic Pumping Slip - 2245 TURNPIKE STREET 9/4/2018 Commonwealth of Massachusetts NED
Cit /Yawn of NORTH ANDOVER
System Pumping Record
Form 4 OV'ER
ME1,41
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 2245 TURNPIKE ST
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
use the return ----
key. City/Town State Zip Code
VQ 2. System Owner:
MICHAEL SAWYER
Name
Address(if differentfrom
.location)
City/Town State Zip Code
-fefep-hone Number
B. Pumping Record
8/13/18 1500
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: F-1 Cesspool(s) R Septic Tank ❑ Tight Tank ❑ Grease Trap
R Other(describe):
4. Effluent Tee Filter present? El Yes ❑ No If yes, was it cleaned? El Yes F-1 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
---------------
8/13/18
SignatureofHauler Date
..........
Signature of Receiving Facility(or attach facility receipt) Date
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