HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 2240 TURNPIKE STREET 5/4/2020 Commonwealth of Massachusetts IRECENED
City/Town of NORTH ANDOVER t'1r' 0 ZO��
System Pumping Record TpWNOF%OKAH`��
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Form 4
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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, 2240 TURNPIKE ST
use only the tab
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
use the return — -
key.
City/Town State Zip Code
dl_ 11 2. System Owner:
V� ANNA FERRARI
Name
xenon
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 4/22/20 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 H_79406
Name Vehicle License Number
J'S SEPTIC & DRAIN
Company
7. Location where contents were disposed:
GLSD _
4122/20
Sign Date
ignature of Receiving Facility(or attach facility receipt) Date
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