HomeMy WebLinkAbout- Septic Pumping Slip - 2135 TURNPIKE STREET 1/24/2019 < F"ZIECEIVED
"L\ Commonwealth of Massachusetts
"HI
go City/Town of NORTH ANDOVER "V"H 10 "1 Ik
System Pumping Record 'rOVVN O1 �ia�0duMT)()V[-R
11EAU]i DE'PAFO MENT
Form 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 CIVIR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 2135 TURNPIKE ST ......
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
use the return
key. State
.
City/Town State Zip Code
2. System Owner:
VQ
JIM CHEAPAS
'Na me-
Address(if different from location)
-- ------------
City/Town State Zip Code
e lephone Number
B. Pumping Record
1, Date of Pumping 12/20/18 2. Quantity Pumped: 1500
Date Gallons
3. Component: ❑ Cesspool(s) M Septic Tank El Tight Tank El Grease Trap
El Other(describe):
4. Effluent Tee Filter present? F-1 Yes El No If yes, was it cleaned? F-1 Yes R 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
12/20/18
Signature of Hauler Date
------------------------ ------
--sigr�afdre-cd Receiving Facili-fy'-(-o--r-attach facility receipt) Date
t5form4.doc-11/12 System Pumping Record-Page 1 of 1