HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1055 SALEM STREET 11/28/2022 FCE'�Fa
Commonwealth of Massachusetts �
City/Town of NORTH ANDOVER Noy
System Pumping Record fowN0- 28 2022
Form 4 11SAt'rly gRTryDC��
M EPI
DEP has provided this form for use by local Boards of Health. Other forms may be used, bufthe
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, 1055 SALEM ST
use only the tab
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
use the return CityfTown State Zip Code
key.
2. System Owner:
JOSE RODRIGUEZ
--.—.--
Name
rerun
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 11/14/22 ----_- 2 Quantity Pumped: 1500
Date Gallons
3. Component: ❑ Cesspool(s) N Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? N Yes ❑ No If yes, was it cleaned? N Yes ❑ No
5. Observed conditior 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
�. 11/14/22 _
Signa e ofj5jLFr7 Date
Signature of Receiving Facility(or attach facility receipt) Date
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