HomeMy WebLinkAboutSeptic Pumping Slip - 1469 SALEM STREET 12/28/2015 Commonwealth of Massachusetts
City/Town of NORTH ANDOVER, MASSACHUSETTS
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. The System Pumping Record must
be submitted to the local Board of Health or other approving authority.
A. Facility Information
Important:
When filling out 1. System Location:
forms on
the
computer, use 1469 SALEM STREET
only the tab key Address
to move your N.ANDOVER MA 01845
cursor-do not City/Town State Zip Code
use the return
key. 2. System Owner:
VQ LORRIE ODAMS
Name
'Address(if different from location)
City[Town State Zip Code
v,
978-258-9780
Telephone Number
B. Pumping Record
1. Date of Pumping 09/17/15 2. Quantity Pumped: 1,000
Date Gallons
3. Type of system: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 001 No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
GOOD
6. System Pumped By:
ROGER ROBEY 7626AR
Name Vehicle License Number
SOUCY SEWER SERVICE INC
Company
7. Location where contents were disposed:
G.L.S.D.
Signature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
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