HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 199 STONECLEAVE ROAD 1/12/2023 Commonwealth of Massachusetts RECEIVED
City/Town of NORTH ANDOVER
System Pumping Record
Form 4 7OWN OF T NORTH A DOVF
M HEALTH
ENT
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 199 STONECLEAVE RD
key to move your Address
cursor-do not NORTH ANDOVER _ _ MA 01845
use the return
key. CitylTown State Zip Code
00--Il 2. System Owner:
V �A MIKE CORLISS
Name -- —_
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 150
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
f.� 1/9/23 _
Signs a of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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