Loading...
HomeMy WebLinkAboutSeptic Pumping Slip - 12-12-2024 - Septic Pumping Slip - 62 WINTERGREEN DRIVE 12/12/2024 Commonwealth of Massachusetts Town o a h - W City/Town of NORTH ANDOVER n ©V�r System Pumping Record - Form 4 DEC 18 2024 DEP has provided this form for use by local Boards of Health. OR s ay be used, but the information must be substantially the same as that provided here MNELsubmitted ck with your local Board of Health to determine the form they use. The System Pumping Recor 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 62 WINTER GREEN DR _........ key to move your Address cursor-do not NORTH ANDOVER MA 01845 use the return - ... _ key. City/Town State Zip Code 2. System Owner: r� DAN ARMET - — Name serum Address(if different from location)_ CitylTown State Zip Code Telephone Number _. -- ---- ... -----------....._..__..._._..._.._...._.__....._._. _ ....... B. Pumping Record 12/12i24 500 1. Date of Pumping _...-_ 2. Quantity Pumped: 1 1 Date Gallons 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 7. Location where contents were disposed: GLSD 12/12/24 Signatu of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc• 11/12 System Pumping Record•Page 1 of 1