HomeMy WebLinkAboutSepitc Tank - Septic Pumping Slip - 273 BERRY STREET 11/22/2021 Commonwealth of Massachusetts RECEIVED
City/Town of NORTH ANDOVER
m System Pumping Record
a
TOWN OF NORTH ANDOVER Form 4
°` rc HEALTH DEPARTMENT
�M
DEP has provided this form for use by local Boards of Heealth. 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. Thie 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.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, 273 BERRY ST
use only the tab
key to move your Address
cursor-do not NORTH ANDOVER _ MA 01845
use the return City/Town State Zip Code
key.
2. System Owner:
JOSH SEIDEL
Name --
etrrn
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 11/1/21 2. (quantity Pumped: 1000
Date Gallons
3. Component: ❑ Cesspool(s) ® Septic 1-ank ❑ 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
J'S SEPTIC & DRAIN
Company
7. Lo�D�
here contents were disposed:
G
ate"' 11/1/21
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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