HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 75 WINDSOR LANE 8/23/2022 Commonwealth of Massachusetts
W City/Town of NORTH ANDOVER 'aEc�+��°
System Pumping Record 2p2Z
u Form 4 p,�G 3 NocvE�
DEP has provided this form for use by local Boards of Health. Other forms may be�t�ecgR� N� MEt.1S
information must be substantially the same as that provided here. Before usi� pjgIA eck with your
local Board of Health to determine the form they use. The System Pumping Recdr� 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 75 WINDSOR LANE
------- -- ---
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� KRISTINE PERNA _
Name
iertrn
Address(if different from location)
CityFrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 8/12/22 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 CONDITION
6. System Pumped By:
JAY CURRIER H79406
Name Vehicle License Number
J'S SEPTIC & DRAIN
Company
7. Location where contents were disposed:
GLSD
8/12/22
Si to er Date
Signature of Receiving Facility(or attach facility receipt) Date
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