HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 308 CAMPBELL ROAD 7/12/2022 Commonwealth of Massachusetts
W City/Town of N ANDOVER RECEIVED
System Pumping Record JUL 12 2022
Form 4
4M
TOWN OF NORTH ANDOVER
DEP has provided this form for use by local Boards of Health. Other formsKM-h*IDEPARIFlASM
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 308 CAMPBELL RD
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
use the return ---— - -
key. City/Town State Zip Code
�11 2. System Owner:
VA STEVE TESSLER
Name
ienm
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 7/8/22 - - - 2. Quantity Pumped: 1000 -
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 w e contents were disposed:
GLSD
7/8/22
Si ature 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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