HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1423 SALEM STREET 6/1/2021 Commonwealth of Massachusetts r ��„�
W City/Town of NORTH ANDOVER
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System Pumping Record Jv„ , -UZ1
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Form 4 QF NORTH ANOOVER
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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.
RECEIVED
A. Facility Information
Important:When JUty 0 2021
filling out forms 1. System Location: TOWN OF NORTH ANDOVER
on the computer,
use only the tab 1423 SALEM ST HEALTH DEPARTMENT
key to move your Address
cursor-do not NORTH ANDOVER _ MA 01845
use the return key. City/Town State Zip Code
�1 2. System Owner:
V� ISABELLA INGRAM
Name
iettm
Address(if different from location)
City,rTown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 5/25/21 _ 2. Quantity Pumped: 1500
Date Gallons
3. Component: ❑ Cesspool(s) E Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
GOOD
6. System Pumped By:
JAY CURRIER H7940_6
Name Vehicle License Number
TS SEPTIC & D
Company ,�j�
7. Location whe c 0f1� . d"-%.
GLSD .00
5/25/21 ------------
Signature&4aule7r Date
Signature of Receiving Facility(or attach facility receipt) Date
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