HomeMy WebLinkAboutSeptic Pumping Slip - 2017 Salem - Septic Pumping Slip - 2017 SALEM STREET 10/25/2024 Commonwealth of Massachusetts
City/Town of NORTH ANDOVER
w� System Pumping Record
�xsu
.` 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 2017 SALEM ST
_..._____ _.._.__ _.
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
use the return _ _._
key. CityfTown State Zip Code
2. System Owner:
r CASSANDRA DELOSSANTOS
Name _
renrn
Address(if different from location)
CityCfown State Zip Code
Telephone Number
_._-.......
__
B. Pumping Record
10/25/24 1500
1. Date of Pumping - L
2. Quantity Pumped: ---_
Date all ans
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
tea,.
7. Locatiq '�w" re contents v7,e disposed:
GLS 10 _. _.
10/25/24
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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