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HomeMy WebLinkAbout- Septic Pumping Slip - 1475 TURNPIKE STREET 9/4/2018 Commonwealth of Massachusetts C F City/Town of NORTH ANDOVER v � System Pumping Record Form � forms DEP has provided this form for use by local Boards of Health. Other o m e 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 1475 TURNPIKE ST. key to move your Address _._...__.._..__..__.,...._...__..__......._...-._.---------..____ cursor-do not NORTH ANDOVERMA 01845 use the return _... _ key. City/Town State Zip Code 2, System Owner: rye WILL SZETO Name IEffN71 Address(if different from location) City/Town State Zip Code ephone Number B. Pumping Record _......_._._._ Tel 1. Date of Pumping ---8/17/18 - - - 2. Quantity Pumped: 1875 __.........._..__........_._._............. _ Date Gallons 3. Component: ❑ Cesspool(s) R Septic Tank ❑ Tight Tank ❑ Grease Trap ® Other(describe): __.._.......__.._.......__.....__ ___.....a.._.a.................___.---__._-- 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: G LS D tea' x'' ,.,1,¢,.�`✓4k,+W.mr��_ ___...... .,.._.._.m._._,_. ___.— ___.._..._._,_... 8/17/18 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1