HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 1929 SALEM STREET 8/8/2025 Commonwealth of Massachusetts
City/Town of NORTH ANDOVER
System Pumping Record
4 20
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may bq�6egL byt the
information must be substantially the same as that provided here. Before using this form, c lbptwiith 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 1929 SALEM ST ----------- ------- ........--------
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
use the return City/Town State Zip Code
key.
2. System Owner:
MAGAURI RODRIQUEZ
................. -----------------------..............
me
ern
................... ......................
Address(if different from location-).................................
.............. ..............
-City/Town -- -State Zip Code
Telephone, - --Number" -- —-- -
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped: 1500
DateGallons
3. Component: ❑ Cesspool(s) Z Septic Tank F-1 Tight Tank M Grease Trap
F-1 Other(describe): --------
4. Effluent Tee Filter present? Z Yes M No If yes, was it cleaned? Z Yes ❑ No
5. Observed condition of component pumped:
GOOD CONDITION
----------------- .......11-1-1-1-11 ................................... ............ ........... -------
6. System Pumped By:
JAY CURRIER H79406
Name Vehicle License Number
J'S SEPTIC & DRAIN
Company
7. Location wh tents were disposed:
L _P_A
...................................... .............................................
8/8/25
Signature of Hauler Date
- i----------------------- —- -----------------------------
Signature of Receiving Facility(or attach facility receipt) Date
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