HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 160 BOSTON STREET 6/12/2025 Commonwealth of Massachusetts Town � �
- - City/Town of NORTH ANDOVER Andover
Z
System Pumping Record
Form 4 JUN 12 2025
Y^' DEP has provided this form for use by local Boards of Health. Other f ms,_�mmay be used, but the
information must be substantially the same as that provided here. Be iadth p��1 ith your
local Board of Health to determine the form they use. The System Pumping Record I L itted 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 160 BOTSON ST
_ - -- ---
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
use the return --- ----
key. - City/Town State Zip Code
2. System Owner:
t SUSAN HAZANVARIAN
Name
retarn
Address(if different from location)
__..._.... _ -- --- - . ---
City/Town State Zip Code
Telephone Number
............. - - - ---- -._._._....._......................................_..................--- ...---- — — -.._....__-......._-- ......
B. Pumping Record
1. Date of Pumping 5/23/25 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
TS SEPTIC & DRAIN
Company
7. Location where contents were disposed:
GLSD
5/23/25
Sign ur tau er no Date
_ ---- - .. ._._...
nature of Receiving Facility(or attach facility receipt) Date
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