HomeMy WebLinkAboutSeptic Pumping Slip - 54 Penni Lane - Septic Pumping Slip - 54 PENNI LANE 9/25/2024 Commonwealth of Massachusetts
City/Town of NORTH ANDOVER
System Pumping Record
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,
use only the tab 54 PENNI LANE ----------- ---------------
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
use the return Ci
key. tyfTown State Zip Code
2. System Owner:
TOM O'NEIL
..........
Name
enm
---------------
Address(if different from location)
City/fawn State Zip Code
.
Telephone Number
.........
B. Pumping Record
1. Date of Pumping 9/25/24 2. Quantity Pumped: 1500
Date ----- Gallons
3. Component: Fj Cesspool(s) Z Septic Tank F-1 Tight Tank Ej Grease Trap
El Other(describe):
4. Effluent Tee Filter present? El Yes ❑ No If yes, was it cleaned? ❑ Yes El 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
-------------------
9/25/24
--—------------ ------------
Sign re ofHauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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