HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 75 WINDSOR LANE 11/12/2020 Commonwealth of Massachusetts
a City/Town of NORTH ANDOVER RECElvED
System Pumping Record
Form 4 Nov 7 ?UZU
M TOWN OF NOR
DEP has provided this form for use by local Boards of Health. Other forms rtp�� r���
information must be substantially the same as that provided here. Before using this o cwith 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, 75 WINDSOR LANE
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:
KRISTINE PERNA
Name --- — ------ ----
etun
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1875
1. Date of Pumping 10/26/20
2. Quantity Pumped.
Date Gallons
3. Component: ❑ Cesspool(s) E Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): — ---- -
4. Effluent Tee Filter present? E Yes ❑ No If yes, was it cleaned? E 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 S Dy'-*09
VAV-Or 10/26/20
5 ature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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