HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1850 SALEM STREET 10/19/2020 Commonwealth of Massachusetts RECEIVED
City/Town of NORTH ANDOVER OCT 19 2020
System Pumping Record TOWN OFWRTHANDOVER
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, 1850 SALEM ST
use only the tab
key to move your Address
cursor-do not NORTH ANDOVER MA 01845 _
use the return Citylfown State Zip Code
key.
2. System Owner:
PAUL HUDSON
Name
Address(if different from location)
CityTrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 10/9120 2. Quantity Pumped: 1500
Date Gallons
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:
GLS
VAV-,Or �+-- 10/9/20
nature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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