HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 2350 TURNPIKE STREET 7/27/2023 Commonwealth of Massachusetts �PPR�M�
City/Town of NORTH ANDOVER ��N tl
a
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.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, 2
use only the tab 350 TURNPIKE ST
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
use the return ------- --- -
use City/Town State Zip Code
r key.
2. System Owner:
r� SCP POOL_ LLINER S
Name
7Bfl//I
_- _.._ __--._-_.._. -
Address(if different from location)
aty/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 7/12/23 -- — 2. Quantity Pumped: 4000
Date Gallons
3. Component: ❑ Cesspool(s) ® Septic Tank ❑ Tight Tank ❑ Grease Trap
PUMP FOR REPAIRS TO PUMPS
❑ 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:
G L S D
7/12/23
Sign re of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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