HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1055 SALEM STREET 5/26/2022 Commonwealth of Massachusetts aECENED
W City/Town of NORTH ANDOVER
System Pumping Record MAY 2 6 NZZ
` M Form 4
TOWN OTN pEP R MENTER
DEP has provided this form for use by local Boards of Health. Other forms mote 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
filling out forms 1. System Location:
on the computer,
use only the tab 1055 SALEM ST
key to move your Address
cursor-do not NORTH ANDOV_ER MA 01845
use the return
key. City/Town State Zip Code
2. System Owner:
JOSE RODRIGUEZ
Name
etrm
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
_
1. Date of Pumping Date 5/20/22 2. Quantity Pumped: 1500
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
6��� . 5/20/22
;,odature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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