HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 2009 SALEM STREET 5/22/2024 W� 'Dvel
� Commonwealth of Massachusetts �er
W City/Town of NORTH ANDOVER 1e 1oti�
} System Pumping Record
Form 4
�M y pp
DEP has provided this form for use by local Boards of Health. Other form ' u d,pbut the
information must be substantially the same as that provided here. BeforeWthls 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, 2009 SALEM ST
use only the tab
key to move your Address
cursor-do not NORTH ANDOVER _ _ M_A_ 0184_5
use the return Cityrrown State Zip Code
key.
2. System Owner:
JEFF MAKOWSKI
Name
rerun
Address(if different from location)
CitylTown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Da9e 4 2. Quantity Pumped: 1500 allons
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
5/9/24
Sign f
ur auler //wtQ.�.L Date
5 ature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1