HomeMy WebLinkAboutSeptic Pumping Slip - 412 SALEM STREET Commonwealth of Massachusetts RECEIVED
cityfTown of_NORTH ANDOVER NO 0 4 J IS
System pumping Record roWiq OF ijoKl'l I ANDOVER
Form 4 lifALTHDEPAR-m��.iq'f
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,ch eck
local Board of Health to determine the form they use.The System pumping Record must be submittwith ed your to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.35E
Facility information
Important:When 1 System Location:
filling out forms —-—-—-—-—
on the computer, 412 SALEM STREET—-——-—---—-—
use only the tab --—-— MA 01845
key to move Your Address OVER -—-—-—- -state Z-�--
cursor-do not NORTHAND P Code
use the return ctyTr—o
key.
2. System Owner:
V0 PETER FRASER
Nam, -—-—-—--
Address—T
fdrifelontf.mlo.catil.n)
State Zip Code
-&Y[Town -— -—-—-—
Telephone Number
B.pumping Record 1000
10126115 2,Quantity Pumped: Gallons
1. Date of Pumping -5-at.- Z Septic ❑Tank Tight Tank ❑ Grease Trap
3. component ❑ Cesspool(s)
[] Other(describe): --— was it cleaned? ❑ Yes ❑ No
4. Effluent Tee Filter present? E] Yes❑ No If yes,
5. Observed condition of component pumped:
GOOD CONDITION—.-—-—-—-.——-
6. System Pumped By: H79 406 —-—-——-—-—
JAMES H CURRIER 11 Vehicle��, hsaNumber
Name
SSEPTIC&DRAIN
Company
7 Location where contents were disposed:
10126115 —-—---—-—_——_
Date
Signal re of Hauler -—-—-—-—- —-—-—--