HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 151 ROCKY BROOK ROAD 10/8/2020 Commonwealth of Massachusetts RECEIVED
w City/Town of NORTH ANDOVER OCT 0 8 2020
System Pumping Record TOWN oFNORTHANDOVER
Form 4 HEALTH DEPARTMENT
�M
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, 151 ROCKY BROOK
use only the tab
key to move your Address
cursor-do not NOR_THANDOVER MA 01845
use the return key. City/Town State Zip Code
2. System Owner:
DANTE BALLERINI
Name -
reaan
Address(if different from location)
Cityrr Nn State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 10/2/20 2. Quantity Pumped: 1500
Date 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 where contents were disposed:
GLSD
10/2/20
Sign re of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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