HomeMy WebLinkAboutSeptic Pumping Slip - 202 LACY STREET 11/17/2015 ��
Commonwealth m� Massachusetts
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System Pumping Record
Form 4
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 31OCK8R15.351.
A._ - __''''y Information �
r
Important:When
filling out forms 1. System Location:
on the computer, �U� LA�EySTREET OFNuN' -
uueon|ythe�b `~—�
key to move your auureom "°~~~.^=~^.`..^.`.
cursor'uonot NO DOVE �A U1�4
�emom�m ��
City/Town State ��Codm
key.
2. System Owner:
�--� ROBERTD|CKERGON
Nome
--------
Address(if different from location)
City/Town State Zip Code /
Telephone Number
B. Pumping Record
11/17/15 150O
1 Date 2 Quantity Pumped:� Date � � Gallons
�
3. Component F-1 Cesspool(s) M Septic Tank El Tight Tank El Grease Trap
El Other(describe):
4. Effluent Tee Filter present? El Yes El No |f yes, was itcleaned? El Yea El No
5. Observed condition of component pumped:
GOOD CONDITION
G. System Pumped By:
JAMES H CURRIER || H79 406 �
Name Vehicle License Number �
J' SEPT|C & DRAIN
Company �
7. Location where contents were disposed:
GLGD
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) nuto
t5fonn4doc-11/12 System Pumping Record^Page 1of1
Commonwealth �� Massachusetts
����������[l\�����/" / `�/
��'f^//l� �
"��^ �\�� �
�/ / / NORTH ANDOVER
System Pumping Record
Form 4
DEP has provided this form for use by local Boards ofHealth. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this fonn, 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 nr other approving authority within 14 days from the pumping date in
accordance with 310 CPWR 15.351.
A. Facility Information REQi iVED
Important:When
filling out forms 1� SyehemLocaUon'
on the computer,
72 WINDSOR LANE
use only the tab
key to move your xggmeo �.
cursor do not NORTH ANDOVER MA 01,364
use the return —
key. City/Town State Zip Code
2. System Owner:
�---� ER|NOAVES
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number �
�
B. Pumping Record �
1. Date ofPumping Date 2� Quantity Pumped:pumoad: Gallons
3. Component El Cesspool(s) 0 Septic Tank F-1 Tight Tank El Grease Trap
F] Other(describe):
4. Effluent Tee Filter present? F-1 YeoF� No |f yes, was itcleaned? [l Yea El No
5. Observed condition of component pumped:
GOOD CONDITION
8. System Pumped By:
JAMES H CURRIER || H79 406
Nome Vehicle License Number �
J' GEPT\C & DRAIN �
Company �
7. Location where contents were disposed: �
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) ooma
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