HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 742 BOXFORD STREET 11/30/2021 � Commonwealth of Massachusetts
W City/Town of NORTH ANDOVER
System Pumping Record
r` Form 4
M
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. Tree System Pumping Record must be submitted to
the local Board of Health or other approving authority wi thin 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, 742 BOXFORD 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:
CHRIS HAGERTY
Name
-
Address(if different from location)
City/Town 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 lank ❑ 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
TS SEPTIC & DRAIN _
Company
7. Location where contents were disposed:
GLS
@ti.. 11/22/21
Signature o Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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