HomeMy WebLinkAboutSeptic Pumping Slip - 548 Forest - 11/19/2024 - Septic Pumping Slip - 548 FOREST STREET 11/19/2024 Commonwealth Massachusetts
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NORTH ANDOVER
System Pumping
Record
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Form 4
DEP has provided this form for use by |onu| 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 |ooe| Board of Health or other approving authority within 14 days from the pumping date in
accordance with 31OCK4R15.351,
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A~ Facility Information
Important:When
filling out forms 1. System Location:
on the
use only the tab 548 FOREST ST. - _ ` .
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cursor-do not '
NOR
TH ANUOVER K�A� 01845
use the��m
way. City/Town State ' Zip Code
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2. System Owner:
�---^ TE[N|EKA PERALTA
Name
City/Town State Zip Code
Telephone Number
B. Pumping Record
11/18/24 1500
1. Date ofPumping Du 11� 2. Quantity Pumped: Gallons
3. Component: R Cesspool(s) Septic Tank R Tight Tank [l Grease Trap
[] Other(describe):
4. Effluent Tee Filter present? El Yes Fl No |f yes, was itcleaned? Yes Fl No
5. Observed condition of component pumped:
GOOD CONDITION
6. System Pumped By:
JAY CURRIER H79406
Name Vehicle License Number
J'S SEPTIC & DRAIN
mpany
7. Location where contents were disposed:
GLSD
11/19/24
signature ofReceiving Facility(or attach facility receipt) Date
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