HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 2302 TURNPIKE STREET 9/6/2022 ECENE0
Commonwealth of Massachusetts
City/Town of NORTH ANDOVER SEp 06 jaz
} System Pumping Record ,;} N;, THANDE° a
Form 4 -Ta."EALTH DEPARTM
M
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, 2
use only the tab 350 TURNPIKE RD
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
use the return — — - --- - ---- -
City/Town State Zip Code
key.
2. System Owner:
NO- MID OFFICE PARK
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
Date 8/31/22 5000
_ - 2. 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 CONDITION
6. System Pumped By:
JAY CURRIER H79406
Name Vehicle License Number
J'S SEPTIC & DRAIN
Company
7. Location where contents were disposed:
GLSD
Xeol 8/31/22 _
Sig ure of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc• 11/12 System Pumping Record•Page 1 of 1
REG��V�v
Commonwealth of Massachusetts SEP o6tio12 vER
= City/Town of NORTH ANDOVER o��NPN�Nt
System Pumping Record o _IAA Pa�M
r` Form 4 N
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 2350 TURNPIKE RD
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� SCP - NO MID OFFICE PARK
Name
rerun
Address(if different from location)
CitylTown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
Date8/31/22 1500
— 2. 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 CONDITION
6. System Pumped By:
JAY CURRIER H79406
Name Vehicle License Number
J'S SEPTIC & DRAIN
Company
7. Location where contents were disposed:
GLSD
G%l2G►t /� �'`�— -- 8/31/22
Si lure of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc• 11/12 System Pumping Record•Page 1 of 1
RECE►QED
Commonwealth of Massachusetts
W City/Town of NORTH ANDOVER SEP 062022
System Pumping Record Or NORTHANDOVER
N DEPARTMENT
Form 4 T�HEALTH
'G M
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 2350 TURNPIKE RD - -
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� NO- MID OFFICE PARK-B
Name -— — - ---
rewn
- — - - — ---— ---- - —
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 8/31/22 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:
GLS
--------------------
/6 8/31/22 --
- — - -
gnature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc• 11/12 System Pumping Record•Page 1 of 1