HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 116 CROSSBOW LANE 6/11/2021 Commonwealth of Massachusetts �F�F/
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City/Town of NORTH ANDOVER t JON
System Pumping Record Htiz�oo,QTyq`O l
Form 4 Fp�R lv
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 CM 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location.-
on the computer, 116 CROSSBOW 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
11 2. System Owner:
V� RUBIN ESTADA
Name ---- ---
�un
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 6/2/21 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 H7940.6
Name Vehicle License Number
TS SEPTIC & DRAIN
Company
7. Location where contents were disposed:
GLSD
6/2/21
Signs a of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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