HomeMy WebLinkAbout- Septic Pumping Slip - 160 CARLTON LANE 11/26/2018 Commonwealth of Massachusetts
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City/Town of NORTH ANDOVER CEIVE
System Pumping Record wov
Form 4 -1,oWt,j OF KA� I 04)OV ER
DEP has provided this form for use by local Boards of Health. Other forms may be use , 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 CIVIR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 160 CARLTON LANE
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
use the return City/Town "Z-,i p Code
—e
key.
VQ 2. System Owner:
DARREN WINNIE
Name
retrain
Address(if different from location) ,-
Cityfrown State Zip Code
Telephone Number
B. Pumping Record
10/31/18 2. Quantity Pumped: 1750
1. Date of Pumping -bate Gallons
3. Component: ❑ Cesspool(s) M Septic Tank Ej Tight Tank ❑ Grease Trap
F1 Other(describe): -.1..........
4. Effluent Tee Filter present? n Yes ❑ No If yes, was it cleaned? El Yes El 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 •
10/31/18
Signature of Hauler Date
...........
Signature of Receiving Facility(or attach facility receipt) Date
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