HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 205 CAMPBELL ROAD 10/5/2022 Commonwealth of Massachusetts ,DECEIVED
City/Town of NORTH ANDOVER
System Pumping Record MAy p 5 2022
M r Form 4
;F NOr;rH ANDO VER
TGA'; jMEN
DEP has provided this form for use by local Boards of Health. Other forrr4fva"gFc dA, 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
filling out forms 1. System Location:
on the computer, 205 CAMPBELL RD
use only the tab
-------- -----------
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
use the return - - - - -- - - -
key.
City/Town State Zip Code
2. System Owner:
t� MIKE OBRIEN
Name
mnm
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
_
1. Date of Pumping 4/29/22 - 2 1000
Date Quantity Pumped: 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:
GLSD
4/29/22 -
le Date
Signature of Receiving Facility(or attach facility receipt) Date
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