HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 40 DUNCAN DRIVE 7/24/2024 Commonwealth of Massachusetts � el
City/Town of -�� a °
F North Andover
System Pumping Record ti 4 tioti�
Form 4 �VL
DEP has provided this form for use by local Boards of Health. Other forms may 4e-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 Systertf#bmping 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, 40 Duncan Drive
use only the tab
key to move your Address
cursor-do not North Andover MA 01845
use the return City/Town State Zip Code
key.
2. System Owner:
Mottolo residence
Name
Address(if different from location)
City/Town State Zip Code
917-312-1279
Telephone Number
B. Pumping Record
6.18.24 1500 gallons
1. Date of Pumping 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:
6. System Pumped By:
Andrew Holland
Name Vehicle License Number
Service Pumping & Drain Co., Inc.
Company
7. Location where contents were disposed:
GLSD
Y'a&4t,:21e 6.18.24
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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