HomeMy WebLinkAboutSeptic Pumping Slip - 505 FOREST STREET 12/28/2015 i
Commonwealth of Massachusetts 1
City/Town of NORTH ANDOVER, MASSACHUSETTS 1
System Pumping Record
Fortes 4
7A.
DEP has provided this form for use by local Boards of Health. The System Pumping Record must
be submitted to the local Board of Health or other approving authority.
A. Facility Information
Important:
When filling out 1. System Location:
forms the
computer, use 505 FOREST STREET
only the tab key Address
to move your N.ANDOVER MA 01845
cursor-do not City/Town State Zip Code
use the return
key. 2. System Owner:
rQ JACK RAYNER
Name
Address(if different from location)
Cityfrown State Zip Code
508-641-5561
Telephone Number
B. Pumping Record
1. Date of Pumping Date 08/24/15 2. Quantity Pumped: 1,000
Gallons
3. Type of system: ❑ Cesspool(s) FNI Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 01 No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
GOOD
6. System Pumped By:
ROGER ROBEY 7626AR
Name Vehicle License Number
SOUCY SEWER SERVICE INC
Company
7. Location where contents were disposed:
G.L.S.D.
Signature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
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