HomeMy WebLinkAbout- Septic Pumping Slip - 100 LACONIA CIRCLE 11/26/2018 . . . ........ :
Commonwealth of Massachusetts RECEIVED
City/Town of NORTH ANDOVER N(")V 2 (31 01
g = System Pumping Record
Form 4 iEAL lII DEPN� ".I.'MENT
DER 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 100 LACONIA CIRCLE
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
use the return _. __...� _....._.... _._ _...
key.
City/Town State Zip Code
2. System Owner:
r JEFF CONTI
Name
retwp
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
11/13/18 1500
1. Date of Pumping — —Date L a llan
2. Quantity Pumped: s -------
3. Component: ❑ Cesspool(s) ® 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 Vehicle License Number
J"S SEPTIC & DRAIN
Company
7. Location where contents were disposed:
GLSD
<42 r ..a... __ r f a 11/13/18
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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