HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 2177 SALEM STREET 5/9/2025 �L\ Commonwealth of Massachusetts
..............
City/Town of NORTH ANDOVER
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
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 Town of North Andover
filling out forms 1. System Location:
on the computer,
use only the tab 2177 SALEM ST
............ ---------------
key to move your Address MAY
cursor-do not NORTH ANDOVER MA
use the return ------- ............................... ----------------------City/Town S I ode
key. State zip c
40--h 2. System Owner: Health Department
MIKE FRITZ
Name
------------- ..................................... ..................
Address(if different from location)
City/Town State Zip Code
-telephone Number--
B. Pumping Record
1. Date of Pumping ..5/9/2-5------- 2. Quantity Pumped: 1500
DateGallons
3. Component: Ej Cesspool(s) Z Septic Tank F-1 Tight Tank n Grease Trap
F-1 Other(describe): 1-1-1-1-1 -- .................................................... .......... ...........
4. Effluent Tee Filter present? F-1 Yes R No If yes, was it cleaned? Fj Yes E] 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_.'
............... ----------
5/9/25
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Sign re of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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