HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1459 TURNPIKE STREET 7/12/2022 Commonwealth of Massachusetts RECENED
w W City/Town of N ANDOVER
System Pumping Record JUL 122022
s Form 4 TOWN OF NORTH ANDOVER
" HEALTH DEPARTMENT
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
filling out forms 1. System Location:
on the computer,
use only the tab 1459TURNPIKE _
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
use the return
key. CityfFown State Zip Code
2. System Owner:
t� AYAN CHOUDHURY
Name
enm
Address(if different from location)
CityrTown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 7/8 o/22 2. Quantity Pumped: 12ll00Datns
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 here contents were disposed:
GL
7/8/22
gnature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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