HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 478 BOSTON STREET 9/30/2019 Commonwealth of Massachusetts RECEPIED
City/Town of NORTH ANDOVER SEP 3 0 2019
System Pumping Record
TOWN OF NORTH ANDOVER
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 CM 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,use only the tab 478 BOSTON STREET
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
use the return CityTTown State Zip Code
key.
�11 2. System Owner:
V� SEAN MERRIGAN
Name
reran
Address(if different from location)
CityTTown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 9124/19 2. Quantity Pumped: 1500
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
TS SEPTIC & DRAIN
Company
7. Location where contents were disposed:
GLSD
14A._. 9/24119
Signa Date
S46nature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1
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