HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 2009 SALEM STREET 5/8/2025 Commonwealth of Massachusetts
M - p City/Town of NORTH ANDOVER
w° 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 Town 01 Nolul — ------
Important:When
filling out forms 1. System Location: MAY 2 1 ZQi J
on the computer, 1Y� !�
use only the tab 2009 SALEM RD
- ... _...._...w w.
key to move your Address _ __
cursor-do not lit
use the return - NORTH ANDOVER MA De
key. City/Town state Zip Code
2. System Owner:
rya JEFF MARKOWSKI
...
Name
retrun
_ _. ....
Address(if different from location)
City/Town State Zip Code
Telephone Number ........_ __ .....
...._...._..................._._..._.....__..._._..- -- — _ _---._...-- ----------___._._...__............................._..
B. Pumping Record
1. Date of Pumping 5/8/25 2. Quantity Pumped: 1500 _
Date Gallons
3. Component: ❑ Cesspool(s) ® Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ® Yes ❑ No If yes, was it cleaned? ® Yes ❑ 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 we disposed:
fl
GLSge-off
5/8/25
Signar Date
sign-ativingFacility(or attach facility receipt) Date
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