HomeMy WebLinkAboutSeptic Pumping Slip - 345 BERRY STREET 10/23/2015 Commonwealth m� K�Massachusetts
��C����l����\�����/u / ��/ /v'����������/ /[!��`����
City/Town of NORTH ANDOVER System Pumping Record
Form 4
OEP has provided this form for use by local Boards of Health. Other forms may be uoed, but the
information must be substantially the same as that provided hena. 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 310CyWR1b.351.
RECEIVED
A. Facility Information
Important:When - 2
filling out forms 1. System Location:
nntheunmputer,
TOWN OFNORTHANDOVER
use only the tab 345 BERRY STREET HEAL"PI DEPART-MEW
key hu move your Address
cursor do not
NO MA 01845
uoe�hena�um
key. City/Town State Zip Code
2. System {}vvnmr
~---~ JEAN K8AR1EG0UDREAULT
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number �
B. Pumping Record
1O/2�V15 15OO �
1. Date ofPumping Date Gallons
GaUuno �
�
3. Component: El CoaepooKu\ M Septic Tank El Tight Tank El Grease Trap
M Other(describe):
4. Effluent Tee Filter present? F-1 Yes F1 No |f yes, was itcleaned? El Yee Fl No
5. Observed condition of component pumped:
GOOD CONDITION
8. System Pumped By:
JAMES H CURRIER || H79 406 �
Name Vehicle License Number �
. �
J SEPT|C & DRAIN
Company
7. Location where contents were disposed: |
GLSD
Signature,'o-f Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc-11/12 System Pumping Record-Page 1 of 1