HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1055 SALEM STREET 6/5/2023 Commonwealth of Massachusetts
W City/Town of NORTH ANDOVER oEPPR�MEN�
System Pumping Record NEP�TH S Zfl�
Form 4 iV�`�'
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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 1055 SALEM ST
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
use the return City/Town State Zip Code
key.
2. System Owner:
V"Rr� JOE RODR►QUEZ
Name
ronm
-- - -- —
Address(if different from location- )
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 5/15/23 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 where contents were disposed:
GLSD fo'-O' ----- -
5/15/23
�Si�g "Gre, uler Date
Signature of Receiving Facility(or attach facility receipt) Date
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