HomeMy WebLinkAbout- Septic Pumping Slip - 1601 SALEM STREET 12/20/2018 Commonwealth of Massachusetts CEIV D
u City/Town of NORTH ANDOVER
a System Pumping Record � dIw: I�Iii. l.l
Farm 4 M�:.4"
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 1601 SALEM ST
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
use the return ___----- - _..._..-- --_.. __--
key. City/Town State Zip Code
lab 2. System Owner:
MATHEW MERRILL
Name
retwn
Address(if different from location)
City/Town State Zip Code
TeEephane Number
B. Pumping Record
00
1, Date of Pumping bate 12/3/18 2. Quantity Pumped: 10 10nans
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
..... _.-.._.___.w____._ _...._._. . _.......__..____.
Company
7. Location where contents were disposed:
GLSD
nature of Hauler_ _ „✓ 12/3/18
Si __.._.
g er Date .
Signature of Receiving Facility(or attach facility receipt) Date
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