HomeMy WebLinkAbout- Septic Pumping Slip - 9/4/2018 Commonwealth of Massachusetts � � � �'°°'��6� �
.. City/Town of NORTH ANDOVERo 4 "
System Pumping Record
Form 4
M
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, 2
use only the tab 350 TURNPIKE RD
key to move your Address
cursor-do not NORTH ANDOVERMA 01845
usethe return ____.� _._.___... __...... _.....,_...__....�.. ._, _.._.-- — ........w__
key. City/Town State Zip Code
2. System Owner:
Fps NO MID OFFICE PARK-SCP BLDG
Name
F62Y71
Address(if different frarn location}
City/Town State Zip Code
Telephone Number
B. Pumping (Record
1. Date of Pumping 3/17/18 ------ 2. Quantity Pumped: 1500
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
E] Other(describe):
4. Effluent Tee Filter present? ❑ 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
w... ... . / r
8/20/18
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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