HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 45 WELLINGTON WAY 8/25/2020 Commonwealth of Massachusetts
u City/Town of NORTH ANDOVER R�CFjV��
a System Pumping Record qU
Form 4 T� a 25 2D2(1
M �O,rNaRTH
DEP has provided this form for use by local Boards of Health. OtherM N1��r
but the
information must be substantially the same as that provided here. Before using , 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, 45 WELLINGTON WAY
use only the tab — _
key to move your Address
cursor-do not NORTH ANDOVER MA _ 01845
use the return City/Town State Zip Code
key.
2. System Owner:
V� DAN MCKEW
Name
seem
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 8815//20 2. Quantity Pumped: 0 DateGallons
3. Component: ❑ Cesspool(s) E 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
8/5/20
Si r r Date
Signature of Receiving Facility(or attach facility receipt) Date
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