HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 75 WINDSOR LANE 9/18/2019 Commonwealth of Massachusetts RECEIVED
City/Town of NORTH ANDOVER SEP 18 2019
System Pumping Record ?01NNOFNORIHANDUVER
, Form 4 HEALTH DEPARTMENT
M
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.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, 75 WINDSOR LANE
use only the tab
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
use the return Cityrrown State Zip Code
key.
2. System Owner:
r� KRISTINE PERNA
Name
ream
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 9/13119 2. Quantity Pumped: 1875
Date Gallons
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:
GL
f 9/13/19
gnature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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