HomeMy WebLinkAbout- Septic Pumping Slip - 265 WEBSTER WOODS 3/14/2019 Commonwealth of Massachusetts RE(.,,EjVED
City/Town of NORTH ANDOVER
System Pumping Record M
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 265 WEBSTER WOODS LANE ...............
key to move your Address
cursor-do not
NORTH ANDOVER MA 01845
use the return key. City/Town State Zip Code
2. System Owner:
VQ STEVE STABILE
Name
arrnn
Address(if different from location) ..........
------------
City/Town State Zip Code
-Telephone Number
B. Pumping Record
1, Date of Pumping 2/5/19 2. Quantity Pumped: 1000
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank F-1 Grease Trap
n Other(describe):
4. Effluent Tee Filter present? E] Yes F1 No If yes, was it cleaned? 0 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
2/5/19
Signature of Hauler Date
Signature of Receiving-Facility(or attachfacility receipt) Date
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