HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 940 FOREST STREET 4/14/2025 Commonwealth of Massachusetts Town Of"fth AndbVer
City/Town of NORTH AN DOVE R
System Pumping Record APR 2 8 2025
Form 4
DEP has provided this form for use by local Boards of Health. Other A940b
information must be substantially the same as that provided here. Before using thisrm, the
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 940 FOREST ST
...................... ................... ------------ ------------------------ ---------
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
usethe return ---- . . ............ .................. ............................................. ..............
key. City/Town State Zip Code
40---h 2. System Owner:
SANTI DEMOLINO
Name
rerun
Address(if different from location)
--------------------- . .......
city State Zip Code
Telephone Number
B. Pumping Record
4/14/25 1, Date of Pumping 2. Quantity Pumped: 1500
date ----- -------- Gallons
3. Component: ❑ Cesspool(s) Z Septic Tank F-1 Tight Tank El Grease Trap
El Other(describe): .....................
4. Effluent Tee Filter present? R Yes El No If yes, was it cleaned? M Yes El No
5. Observed condition of component pumped:
GOOD CONDITION
....................--------�-11-1-��--l-,---------�-----�--------I-----------------........... -------
6. System Pumped By:
JAY CURRIER H79406
............... ---
----
Name Vehicle License Number
J'S SEPTIC & DRAIN
Company
7. Location where contents re disposed:
GLSD
................
P
Z
4/14/25
--------------------- ---------- ------
Sign.rreeof�Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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