HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 1055 SALEM STREET 5/21/2025 Commonwealth �� 8�Massachusetts
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System Pumping Record
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 mr other approving authority within 14 days from the pumping date in
accordance with 31OCK8R15.351.
A. Facility Information Town of Wh Andover
Important:When
filling out forms 1. System Location:
on the computer,
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use only the tab /voo Sr^Low o/ */
keyto move your adUvase
cursor'do not
NORTH ANOOVER MA 01845
use the return
key. ^"'''"w'' S`*,» Healfil Depaf"Lwnt
2. System Owner:
�---' JDSEROOR|GUEZ
Name
Address(if different from location)
utwvown State Zip Code
Tn|epxqnwwum 11 ber 11
B. Pumping Record
1. Date of Pumping Date
2� Quantity Pumped: 1500
Ganona
3. Component: M Cesspool(s) F] Septic Tank F1 Tight Tank El Grease Trap
F] Other(describe):
4. Effluent Tee Filter present? N Yes [l No |f yes, was itcleaned? N Yes E] No
5. Observed condition of component pumped:
GOOD CONDITION
O. System Pumped By:
JAY CURRIER H704DO
-Name- __ -- __- - Vehicle License Number
J'S SEPTIC & DRAIN
ompany
7. Location where contents were disposed:
GLSD
5/15/25
ignature of Receiving Facility(or attach facility receipt) Date
t5form4.goc^ 11/12 System Pumping Record `Page 1nf1