HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 158 OLYMPIC LANE 3/17/2025 Commonwealth of Massachusetts Town Of North Andover
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City/Town of NORTH ANDOVER
MAR 2 4 2025
System Pumping Record
Form 4
"I'll DepartmRq
DEP has provided this form for use by local Boards of Health. Other forms may be used, b
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 158 OLYMPIC LANE
11- - -- ------------------- ------------- .........................................-----------------
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
use the return ------------ -
key. City/Town State Zip Code
2. System Owner:
VERONICA CAMIRE
Name
rvrwrr
Address(if different from location)
City/Town State Zip Code
-fel-ep-hone Number
- - ------ . ..............
B. Pumping Record
3/17/25 1500
1. Date of Pumping bate-- 2. Quantity Pumped: Gallons
3. Component: El Cesspool(s) Septic Tank ❑ Tight Tank F1 Grease Trap
Fj Other (describe): ....................
4. Effluent Tee Filter present? E] Yes F No If yes, was it cleaned? ❑ Yes F-1 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:
-GLS D
i ----------- ----3----/----1---7-
/25 ll - --- ----------- ..........
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s4rawHauer Date
Signature Receiving Facility(or attach facility receipt) Date
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