HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 173 INGALLS STREET 5/12/2020 Commonwealth of Massachusetts
W City/Town of NORTH ANDOVER RECEIVED
System Pumping Record MAy 12 ZOZO
Form 4
TOWN OF NORTH ANpOVER
H DEPPRTMENT
DEP has provided this form for use by local Boards of Health. Other forms m useG 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, 173 INGALLS RD
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
2. System Owner:
MARK GUARINI
Name --- --- - --
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 5D/a Gallons
6//20 - 2. Quantity Pumped: 1500 -
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:
GLSD
--- �L 5/6/20
Sign re of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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