HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1806 SALEM STREET 12/13/2021 Commonwealth of Massachusetts
City/Town of NORTH AN DOVE R
} - System Pumping Record
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. 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.
A. Facility Information
Important:When TOWN OF t3URTHANWVFR
filling out forms 1. System Location: FIFAt.TMTMENT
on the computer,
use only the tab 1806 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:
r� SCOTT DIAMOND
Name -- - -
renm
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 12/9/21- - - 2. Quantity Pumped: —1500
------- - -- -- -----
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
J'S SEPTIC & DRAIN
Company
7. Location where contents were disposed:
GLS
12/9/21
ignature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc• 11/12 System Pumping Record•Page 1 of 1
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