HomeMy WebLinkAbout- Septic Pumping Slip - 1929 SALEM STREET 6/10/2019 Commonwealth of Massachusetts
C il /Town of N ORTH AN OV R
System Pumping Record
. ........
H'[1[T1 0
Form "
DEP has provided this,form use by,local, Boards of Health. Other forms may be,use�d, but the
information must be substantially the same as that providied 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 R 1516�3,51.
A. Facility Information
Important:When
fiffing out forms 1 System Locafion,,
on the cornputer,,
use only the tab 1929 SALEM ST
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
use the return key City[Town State Zip Code
.
tab 2. System Owner,.,
MIGAURI RODRIGUEZ
Name
16"Un
........ Address It different from location,)
Ci'ty/Tbwn State Zip Code
lephone Number
B. Rumping Record,
5/29/19 1500
1. Date of Pumping Date, 2. Quantity Pumped. Gallons
31. Component- Cesspool(s) Septic Tank Tight Tank Grease Trap
Other(describe)
4. E,ff luent Tee Filter present? Z Yes, E] No If yes, was it cleaned? Z Yes E:1 N o,
5. Observedcondition of component pumped:
6. System Pumped By'.
JAY CURRIER H79406
Name Vehicle License Number
J'S SEPTIC & DRAIN
Company
7,, Location where contents were disposed:
GLSD
77�
5/29/19
Signlg&rer& a'171, r
............-,....................................""".............._`...........................
iginatureof'Receiving Facility(or attach facility receipt) Date
t5form,4.doca 11/12 System Pumping Record Page 1