HomeMy WebLinkAbout- Septic Pumping Slip - 1689 SALEM STREET 11/5/2018 Commonwealth of Massachusetts
RECEIVED
City/Town of NORTH ANDOVER
System Pumping Record NOV 01 ?018
Form 4 -R
TOWN OF NORTH AND WE
j4r_Aj4°4 DEPARTMENT
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 1689 SALEM ST
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
use the return
key. City[Town State Zip Code
2. System Owner:
rab
MARK SHEA
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
10/11/18 1500
1. Date of Pumping bite 2. Quantity Pumped: -Gal I o ns.......... ...............
3. Component: F-1 Cesspool(s) E Septic Tank El Tight Tank F1 Grease Trap
n Other(describe): .................
4. Effluent Tee Filter present? El Yes [:1 No If yes, was it cleaned? Yes El No
5. Observed condition of component pumped:
-GOOD ...............
6. System Pumped By:
JAY CURRIER H79406
Name Vehicle License Number
TS SEPTIC & DRAIN
Company
7. Location where contents were disposed:
1GLSD
-----------
10/11/18
Signature of Hauler Date
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Signature of Receiving Facility(or attach facility receipt) Date
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