HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 227 GRANVILLE LANE 11/25/2019 Commonwealth of Massachusetts
City/Town of NORTH ANDOVER RECEIVED
a System Pumping Record NOV 25 2019
Form 4 TOWN OF NORTH ANDOVER
�M pp MM NN
DEP has provided this form for use by local Boards of Health. Other forms bePuM, ut 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,use only the tab 227 GRANVILLE LANE
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
use the return City/Town State Zip Code
key.
00----1 V� 2. System Owner:
JAKE CHACE _
Name
rerun
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 11/20/19 2. Quantity Pumped: 1500
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 wh re contents were disposed:
GLSD
014
11/20/19
SigKature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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