HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1055 SALEM STREET 6/1/2021 Commonwealth of Massachusetts RECEIVED
u City/Town of NORTH ANDOVER JUy 0 1 2021
System Pumping Record
r Form 4 TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
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 CM 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 1055 SALEM ST
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
use the return ----- - --
key. City/Town State Zip Code
2. System Owner:
JOSE RODRIGUEZ
Name ------ -
ream
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 5/25/21 2. Quantity Pumped: 1875
Date Gallons
3. Component: ❑ Cesspool(s) ® 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 H79406
Name Vehicle License Number
YS SEPTIC & DRAIN
Company
7. Location where contents were disposed:
GLSD
ZAf 5/25/21
Slure of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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