HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 199 STONECLEAVE ROAD 1/23/2024 Commonwealth of Massachusetts
W City/Town of NORTH ANDOVER
System Pumping Record o�P
Form 4
DEP has provided this form for use by local Boards of Health.�ther form be use the
information must be substantially the same as that provided here. Befor-6tivs ng this fo check with your
local Board of Health to determine the form they use. The System Pumping Record` ubst 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, 199 STONECLEAVE
use only the tab
key to move your Address
cursor-do not NORTH ANDOVER MA _ _ 0184_5
use the return - - - - - -—
key.
CityfTown State Zip Code
1 2. System Owner:
V� MIKE CORLIS
-- -- ——
Name
renm
Address(if different from location)
City/Town State Zip Code
-------- - ------
Telephone Number
B. Pumping Record
1. Date of Pumping 1/5/24 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 'sposed:
GLSD
1/5/24
Signature Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1