HomeMy WebLinkAboutSeptic Pumping Sliip - 314 Boston St �x Commonwealth of Massachusetts
City/Town Of North Andover NOV 2 6 2024
System Pumping Record
Form 4
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DEP has provided this form for use by local Boards of Health. Other forms may f,e 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 314 Boston Street
key to move your Address
cursor-do not North Andover MA 01845
use the return. City/rown State Zip Code r
key.
j 2. System Owner:
Motta residence
IL Name
mun
Address(if different from location)
Cityrrown State Zip Code
978437-0531
Telephone Number
B. Pumping Record
8.15.24 1500 gallons
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) ® Septic Tank ❑ Tight Tank C1 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:
Shawn Miller
Name Vehicle License Number
Service Pumping&Drain Co., Inc.
Company
7. Location where contents were disposed:
GLSD
c15,/Wulc rL r &"' 8.15.24
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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