HomeMy WebLinkAbout- Septic Pumping Slip - 173 INGALLS STREET 4/22/2019 Commonwealth of Massachusetts
City/Town of NORTH ANDOVER
System Pumping Record
„
,. 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 CM 15.351. t
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,use only the tab 173 I NGALLS STREET
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
use the return key, City/Town State Zip-CodeVQ -
2. System Owner:
PETER MASTRANGELO
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping gate ....-...3/15/19 .__...._. .w........ 2. Quantity Pumped: Gallons 1875
75
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 /`
- -- -
3/15/19
Signature of Hauler _._..._ Date -- -
.. ._...... .. _
Signature of Receiving Facility(or attach facility receipt) Date
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