HomeMy WebLinkAbout- Septic Pumping Slip - 107 LIBERTY STREET 1/24/2019 Commonwealth of Massachusetts
City/Town of NORTH ANDO►VER
- System bumping Record
G A
Form 4 � i AL��il.�l
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. t
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,use only the tab 107 LIBERTY STREET
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
use the return _....___._. .._.__._._.. ....-. ._.____.
key. City[Town State Zip Code--
2. System Owner:
r LOUIS CARRILLO
Name
rstwo
Address(if different from location)
.. .__. ___ .._.._-- -- _._.._._ _...._.. __....._.._,,
City/Town State Zip Code
Telephone Number
B. Pumping Record
11/18/1$ 0
1. Date of Pumping __ _.__._,____ 2. Quantity Pumped: 150 150
Date Gallons
3. Component: ❑ Cesspool(s) ® Septic Tank ❑ Tight Tank ❑ Grease Trap
El 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 !
11/18/18
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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