HomeMy WebLinkAboutGreast PT - Septic Pumping Slip - 315 TURNPIKE STREET 2/16/2023 �L\ Commonwealth of Massachusetts . RECEIVED
City/Town Of North Andover 2
03
System Pumping Record FE816 A povsR
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Form 4 OF t`IOEpA EN1
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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, 315 Turnpike St
use only the tab
key to move your Address
cursor-do not North Andover MA
use the return - — _ --
key. City/Town State Zip Code
�1 2. System Owner:
VD�A Merrimack College
Name
reom
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
01/26/2023 4,000.00
1. Date of Pumping Date — 2. Quantity Pumped: Gallons
3. Component: GreasePT (Grease Pumping and Transportation
❑ Other(describe):
4. Effluent Tee Filter present? ® Yes ❑ No If yes, was it cleaned? X❑ Yes ❑ No
5. Observed condition of component pumped:
Good
6. System Pumped By:
Bob Brenton
Name Vehicle License Number
Waste Water Services, Inc. /Heritage Pumping
Company
7. Location where contents were disposed:
Jordan Dairy Farm/Rutland
01/26/2023
Sign ture o Haaler Date
Signature of Receiving_Facility(or attach facility receipt) Date
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