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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 113 BRIDGES LANE 9/23/2024 A�ao,�et Commonwealth of Massachusetts City/Town of NORTH ANDOVER .1\0*1 ` ti System Pumping Record S�Q �3tio Form 4 �er� M DEP has provided this form for use by local Boards of Health. Other forms 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 113 BRIDGE LANE key to move your Address cursor-do not NORTH A.NDOVER MA 01845 _ use the return - --- -- — -- - — ---- key. City/Town State Zip Code 2. System Owner: r� CLAUDIO DOCARMO Name rerun Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 9/5/24 --.-- 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 disposed: GLSD VAZOP ✓_'"'�'� 9/5/24 Signatur6 of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc• 11/12 System Pumping Record•Page 1 of 1