HomeMy WebLinkAboutPumping Record - Septic Pumping Slip - 199 STONECLEAVE ROAD 1/13/2025 Town of NOrth AndoVer
Commonwealth of Massachusetts
City/Town of NORTH ANDOVER
FEB
System Pumping Record 2025
Form 4 Health De
DEP has provided this form for use by local Boards of Health. Other forms may be Ps9ftwont
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 199S TO.N E CLEAVE-, ............... ----------------------
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
use the return CityfTown S.t.a-t I e -ZipCod-e
key.
00--h
2. System Owner:
MIKE CORLIS
Name
Addressranm
_ ___1_ .__ ----1_ .._--—---- - ...........(if different from location)
61-tyr-fo-w-n- State Zip Code
Telephone,
B. Pumping Record
1/13/25 1500
1. Date of Pumping _b_ate____ 2. Quantity Pumped: Gallons
3. Component: F-1 Cesspool(s) E Septic Tank El Tight Tank R Grease Trap
El Other(describe): ................. ............ ............ ..........
4. Effluent Tee Filter present? 0 Yes ❑ No If yes, was it cleaned? Fj Yes r_1 No
5. Observed condition of component pumped:
GOOD CONDITION
--
6. System Pumped By:
JAY CURRIER - H79406
-------- ...... ....... . . . . ............. .......
4am Vehicle License Number
J'S SEPTIC & DRAIN
- - ---------------
-Co-npan-y
7. Location w e contents wer disposed:
GLSD
1/13/25
u ..........................
ign/ure�of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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