HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1806 SALEM STREET 9/25/2024 �LN Commonwealth of Massachusetts e doot
City/Town of NORTH ANDOVER '
System Pumping Record ti5 tioti�
Form 4
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, 1806 SALEM ST
use only the tab _
key to move your Address
cursor-do not NORTH ANDOVER _ _ _ MA 01845
use the return key. City/Town State Zip Code
2. System Owner:
LLIR KARAJA
Name - - -- - - —
renm
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 9/20/24- -- 2. Quantity Pumped: 1500
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
9/20/24
Signat a dl Date
Si ture of Receiving Facility(or attach facility receipt) Date
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