HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1055 SALEM STREET 6/4/2024 Commonwealth of Massachusetts
Aid°vex
City/Town of NORTH ANDOVER
4 0
System Pumping Record soN
Form 4
M l_ f�IV®Y
DEP has provided this form for use by local Boards of Health. Other forrrt 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,
use only the tab 1055-SALEM ST _
key to move your Address
cursor-do not NORTH ANDOVER _ MA 01845 _
use the return Cit /Town
key. y State Zip Code
2. System Owner:
JOE RODRIQUEZ
Name
ienm
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 5/17/24 . _ 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
TS SEPTIC & DRAIN
Company
7. Location where contents were disposed:
GLSD eHauler
_ 5/17/24
ign re o Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc• 11/12
System Pumping Record•Page 1 of 1