HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1689 SALEM STREET 9/27/2022 Commonwealth of Massachusetts V�Scvjeo
w . City/Town of NORTH ANDOVER 2022
System Pumping Record SEP
Form 4 �}� �RtH
M T0\0 jjH IDS?AR
DEP has provided this form for use by local Boards of Health. Other forms may b ' e`d, 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, 1689 SALEM ST
use only the tab
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
use the return -- - ---
key.
City/Town State Zip Code
2. System Owner:
MARK SHEA
Name
rerun
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 9/8/22 _-- 2. Quantity Pumped: 1500
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 CONDITION
6. System Pumped By:
JAY CURRIER__- - H79406
Name Vehicle License Number
J'S SEPTIC & DRAIN _
Company
7. Location contents were disposed:
GLSD
B� 9/8/22
Si§nature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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