HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 20 ROCKY BROOK ROAD 5/12/2020 Commonwealth of Massachusetts RECEIVED
City/Town of NORTH ANDOVER MqY ,4 2020
_ System Pumping Record
Form 4 TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
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,use only the tab 20 ROCKY BROOK RD
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
use the return -- — - -- —
key.
City/Town State Zip Code
2. System Owner:
V� RALPH SAYEGH
- --- _
Name
rensn
Address(if different from location)
CitylTown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping oa4e20 — 2. Quantity Pumped: GaI00
ns
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:
G L Sq-_'7
�'. 5/4/20 _
/haturef Hauler Date
- ------ - -- ._
Signature of Receiving Facility(or attach facility receipt) Date
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