HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 770 BOXFORD STREET 10/31/2022 Commonwealth of Massachusetts �E�E,vtio
W City/Town of NORTH ANDOVER
System Pumping Record o�j 312021
M Form 4 P.ANO0.5R
OvA 0r NpSOS'( N
DEP has provided this form for use by local Boards of Health. Otherrott"V 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, 770 BOXFORD ST
use only the tab
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
use the return CityTTown State Zip Code
key.
2. System Owner:
NELSA ESTSRELLA
Name
ronm
Address(if different from location)
Citylrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 10/27/22 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 CONDITION
6. System Pumped By:
JAY CURRIER H79406
Name Vehicle License Number
J'S SEPTIC & DRAIN
Company
7. Location a contents wer disposed:
GLSD
10/27/22
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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