HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 10 COLONIAL AVENUE 10/16/2023 IL
Commonwealth of Massachusetts OEpaR�M`N�
4 City/Town of NORTH ANDOVER A��N 2023
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, 10 COLONIAL AVE
use only the tab - _ —_ ---
key to move your Address
cursor-do not NORTH ANDOVER MA 01_8_4_5
use the return -------- ---- ----- --
key.
CitylTown State Zip Code
2. System Owner:
r� DAN GILL
Name
renm
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 10/10/23 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 w re contents were disposed:
GLSD
10/10/23
Si ature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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