HomeMy WebLinkAbout- Septic Pumping Slip - 742 BOXFORD STREET 12/20/2018 Commonwealth of Massachusetts R�!,, CEINV!70
City/Town of NORTH ANDOVER HT
System Pumping Record
Form 4 J
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 742 BOXFORD ST
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
use the return ------------
key. City/Town State Zip Code
VQ 2. System Owner:
CHRIS HAGERTY
Name
Ad-dress(if different from m- location)
City/Town State Zip Code
Telephone�Num6er
B. Pumping Record
1. Date of Pumping 12/6/18 2. Quantity Pumped: 1500
Date"- '--- dal'I'o"n"s
3. Component: ❑ Cesspool(s) Z Septic Tank El Tight Tank El Grease Trap
F-1 Other(describe):
4. Effluent Tee Filter present? El Yes F-1 No If yes, was it cleaned? n Yes El No
5. Observed condition of component pumped:
.GOOD --------------------- .....------
& System Pumped By:
JAY CURRIER H79406
Name Vehicle License Number
TS SEPTIC & DRAIN
Company
7. Location where contents were disposed:
GLSD
12/6/18
Signature of Hauler Date
Signature of Receiving Facility(or rak"66 h facility receipt)-- Date . ......
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