HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 205 CAMPBELL ROAD 5/22/2024 Commonwealth of Massachusetts
W City/Town of NORTH ANDOVER
System Pumping Record
Form 4 Mp`(
M
DEP has provided this form for use by local Boards of Health. Other forms may be u a�,, e,f gae`\t_
information must be substantially the same as that provided here. Before i frliheck with your
local Board of Health to determine the form they use. The System Pumpinje�cord 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 205 CAMPBELL RD _
key to move your Address -
cursor-do not NORTH ANDOVER _ MA 01845
use the return !Town — --
key. City/Town State Zip Code
2. System Owner:
MIKE O'BRIEN
Name
rensn
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 5/13/24 1000
p g Date — 2. Quantity Pumped: 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
5/13/24
Signatu of auler Date
Signature of Receiving Facility(or attach facility receipt) Date
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