HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 171 LACONIA CIRCLE 4/11/2025 IV Town of NOrth AndoVer
Commonwealth of Massachusetts
City/Town of NORTH ANDOVER
APR 2 8 2025
System Pumping Record
Form 4 Health Dep r
aq
DEP has provided this form for use by local Boards of Health. Other forms may be used,
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 CIVIR 15.351,
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 171 LACONIA CIRCLE---------------------------
.............................
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
use the return City/Town .......................... State
f a-t-e—1..................... Zip Code
key.
2, System Owner:
JENN ROYSTER
............. ---------------------
Name
ranm
Address(if different from location)
City/Town State —Zip—Code ------- ----------
Telephone Number
B. Pumping Record
1. Date of Pumping 4/11/25 2. Quantity Pumped: 1500
-bate--- Gallons
3. Component: El Cesspool(s) Z Septic Tank r-1 Tight Tank R Grease Trap
El Other(describe):
4. Effluent Tee Filter present? Z Yes F-1 No If yes, was it cleaned? Z Yes F-1 No
5. Observed condition of component pumped:
GOOD CONDITION
6. System Pumped By:
JAY CURRIER H79406
Name Vehicle License Number
TS SEPTIC & DRAIN
Company
7. Location wO,er;e contents were disposed:
GLSD
4/11/25
Si ature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc-11/12 System Pumping Record-Page 1 of 1