HomeMy WebLinkAbout- Septic Pumping Slip - 2200 TURNPIKE STREET 11/5/2018 Commonwealth of Massachusetts
- -- City/Town of NORTH ANDOVER RECEIVED
a System Pumping Record ��
Form 4
"SOWN O°F NOR Tti ANUOVER
DEP has provided this form for use by local Boards of Health. Other forms ml t - 4e
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 200 TURNPIKE S7
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
use the return —_ __.-- ____ _........__.
key. City/Town State Zip Code
2. System Owner:
tab
LARRY TRACEY
Name
ratcwn
Address(if different from location)
City/Town State Zip Code
_...-r
B. Pumping Record
1. Date of Pumping 10/25/1$ 2. Quantity Pumped: .1000
.-- -----
Date Gallons
3. Component: ❑ Cesspool(s) E Septic Tank ❑ Tight Tank [ Grease Trap
❑ 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 Vehocle License Number
J'S SEPTIC & DRAIN
Company
7. Location where contents were disposed:
GLSD
10/25/18
Signature of Mauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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