HomeMy WebLinkAbout- Septic Pumping Slip - 5/2/2019 Commonwealth of Massachusettsof North Andovei,
City/Town
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System Record ID O lkq A
Form, 4 R TME,N''
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DEP has provided this,form for use by local Boards Health. Other forms may be used, but the,
informatibin must be substantially the same as that provided hiere. Before Busing thi's form, check with your
local Board ofHealth 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
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Important:When
filling out forms 1. System Location
on the m �t r rr
use one l the tad
key to,move your Address
cursor-do not 56 AcademyNorte Andover
use the return
Cit rr wry State Zip Code
y
2. System Owner:
r
Namei
r� 136 E t Michigan Ave
Address(if different from l ti rr
49007
lomax
City/Town State Zip Cede
Telephone Number
B. Pump'ing Record 5-1-19 350
1. late of Pumping Date 2. Quantity Pumped: Gallon
3. Component V Cesspool(s) Septic Faro Tight Tank Grease Trap
El I
Other('describe): mm
4. Effluent Tee Filter present? El Yes V No If yes, was it cleaned? El Yes No
5. Observed condition of component,pumped:
Tank has not been pumped n several years.Renioved soiliidmaterials to best oflit .
6. System Pumped By:
1 � T79928
-einy M
Name Vehicle i License Number
Titnoffi'y A.,GMMMumbing Heating
Company
". Location where contents,were disposed,
Greater LaWrence Sanitary -ict
5- 49
J
Signature of Hauler r Date,
Signature of Receiving Facility r attach facility receipt) Date
t rm . *1 112 System Pumping record Page 1 of I