HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 2177 TURNPIKE STREET 5/13/2025 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 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 2177 TURNPIKE ST
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
usethe return �ll,�.I.�111.1�-,�'ll-I'��'ll"....................- _------ -----------
key. City/Town State ToWn of Zip Code
00---h 2. System Owner: NOrth
AndWer
LEANVRO ROSA
-------------------I.............. ----------------
Name 152025
enun
Address(if different from-location) Hea
.__tth
dif� ................I.......................I.................................................... -------
own State eht
-telephone-Number
B. Pumping Record
5/13/25 3000
1. Date of Pumping - ate 2. Quantity Pumped: Gallons
1 Component: ❑ Cesspool(s) Z Septic Tank 0 Tight Tank 0 Grease Trap
TANK & CHAMBER FOR REPAIRS
Ej Other(describe): 1-11,11111 ,................................I............ ---------------
4. Effluent Tee Filter present? Z Yes El No If yes, was it cleaned? Z Yes F_j 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:
GLSD
T -----------
......... 5/13/2/5
. ------
Signature of Fdavler bate
................ ......................
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Signature----o_fReceiving-Facility(or attach facility receipt) Date
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