HomeMy WebLinkAboutSeptic Pumping Slip - 101 Abbott - Septic Pumping Slip - 101 ABBOTT STREET 10/4/2024 Commonwealth
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System Pumping Record
Form 4
DEp has provided this form for use bv local Boards ofHealth, 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 |Voo| Board of Health ur other approving authority within 14 days from the pumping date in
accordance with 31OC[WR15.351.
A. Facility Information
Important:When
filling out fvnna 1. System Location:
on the computer,
use only the tab 101ABBDTTST
key m move your xuumss r-
curspr'do not � '
NORTH ANDOVER MA ' ^ O1845
use mamgum
xev_ _ City/Town _ State Zip Code
2. System Owner: ~
^---^ NNNN| CRUZ
Name
Telvphnnewumbe,
B. Pumping Record
1. Date ofPumping o�e 10/4/24 2� Quantity y Pumped: Gallons
3. Component: Z Cesspool(s) F-1 Septic Tank [:1 Tight Tank Fl Grease Trap
E] Other(describe):
4. Effluent Tee Filter present? Fl Yes Fl No |f yes, was itcleaned? F� Yes Fl No
5. Observed condition of component pumped:
- - - - - GOOD CONDITION -
R. System Pumped By:
JAY CURRIER H79406
Name Vehicle License Number
J'G SEPTIC & DRAIN
ompany
7. Location
GLS
10/4/24
nature of Hauler Date
Signature of Receiving Foc|uy(oreuach facility receipt) Date
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