HomeMy WebLinkAbout- Septic Pumping Slip - 5 CHRISTIAN WAY 12/20/2018 �.._ Commonwealth of Massachusetts RE E 1V 7E',
M - q City/Town of NORTH ANDOVER
system Pumping Record
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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 j
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 5 CHRISITAN WAY
key to move your Address.._w..
cursor-do not NORTH ANDOVER MA 01845
use the return ............__..m.__.__.__._. ---_ _
key. Cityfrown State Zip Code
2. System Owner:
rab MIKE DUNN
Name
reroro
Address(if different from location)
City/Town State Zip Code
_.....__......_................ --
Telephone Number
B. Pumping Record
/18 30 11/
1. Date of Pumping 11/ 0 - - 2Date— . quantity Pumped: 1500
1500
Gallons
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
11/30/18
Signature of HauCer Date
— -_......
Signature of Receiving Facility(or attach facility receipt) Date
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