HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1055 SALEM STREET 5/11/2026 Commonwealth of Massachusetts Town of N ", ` '``°over
k City/Town of NORTH ANDOVER
System Pumping Record MAY 18 2a2
Form 4
rt
DEP has provided this form for use by local Boards of Health. Othe 4 2 Eisaeed, mtthente
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, 1 a55 SALEM ST
use only the tab
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
use the return -
key. CityiTown State Zip Code -
2. System Owner:
JOSE RODRIQUEZ
Name
arsn
Address(if different from location)
City/Town State Zip Code -
Telephone Number Numb
B. Pumping Record _._..__....._
150a
1. Date of Pumping 5/11/26 pate _ 2. Quantity Pumped: 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
-
S — 5/11/26
t i naof auler Date
Signature of Receiving Facility(o 11 r atta 11 c 11 h fa11 cility receipt) Date
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