HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1055 SALEM STREET 11/30/2021 Commonwealth of Massachusetts
City/Town of NORTH ANDOVER
W° 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 proviided here. Before using this form, check with your
local Board of Health to determine the form they use. Trie 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, 1055 SALEM 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:
r� JOSE RODRIQUEZ
Name -- —
�vn
Address(if different from location)
City[T'own State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 11/22/21 2 (Quantity Pumped: 1500 _
Date Gallons
3. Component: ❑ Cesspool(s) ® Septic 1-ank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): —
4. Effluent Tee Filter present? E 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 & DRAIN
Company
7. Location where contents were disposed:
GLS
r_�A�"aA_7 11/22/21
nature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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