HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 2163 TURNPIKE STREET 3/17/2025 Irl.l.
Commonwealth of Massachusetts Town of North Andover
City/Town of NORTH AN DOVE R
MAR 2 4 2025
System Pumping Record
Form 4
Health Dep vr
DEP has provided this form for use by local Boards of Health. Other forms may be ue p t9vt
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,
use only the tab 2163 TURNPIKE RD
............. ...................
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
use the return . ....... ------------
key. CityfTown State Zip Code
2. System Owner:
-JOHN ALEPAKIS
Na
__ _11.111............... ....................... --------
me
........... ----.............. ........................................................ ...........
Address-(if different from location)
City/Town State Zip Code
Telephone
elephone.111,Number
--------
..........
B. Pumping Record
1. Date of Pumping 3/17/25 2. Quantity Pumped: 1500
Date- Gallons
1 Component: ❑ Cesspool(s) Z Septic Tank El Tight Tank F-1 Grease Trap
F1 Other(describe): ''I I.............. ------------------
4. Effluent Tee Filter present? ❑ Yes Fj No If yes, was it cleaned? ❑ Yes M No
5. Observed condition of component pumped:
GOOD CONDITION
............... ..........
& System Pumped By:
JAY CURRIER H79406
.... .......... ........ ........
......
Name Vehicle License Number
J'S SEPTIC & DRAIN
Company
7. Location where contents were disposed:
,GLSD
"for 3/17/25
....................................... ....................----------
signa e of Hauler Date
— ---------
Signature o-f-Receiving Facility--(or-a--t-ta--c--h-f-a-cil'it'y receipt) Date
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