HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 76 BOSTON HILL ROAD 5/15/2023 Commonwealth of Massachusetts
W City/Town of NORTH ANDOVER
System Pumping Record
Form 4
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. �EC'SOSP
A. Facility Information ,;
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Important:When
o'Inithecomputer, N
out forms 1. System Location: OF��ti-�1►�
use only the tab 76 BOSTONHILL 10WN (N
key to move your Address
cursor-do not NORTH ANDOVER MA _ 0184_5_
use the return City/Town State Zip Code
key.
2. System Owner:
t� KEVIN DUBE
Name
enm
Address(if different from location)
0-ty/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 4/24/23 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
TS SEPTIC & DRAIN _
Company
7. Locatio a contents wer isposed:
GLSD �
4/24/23
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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