HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 1601 SALEM STREET 6/12/2025 Commonwealth of Massachusetts
x City/Town of NORTH ANDOVER
System Pumping Record
Form 4
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1. .Y 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 �neI"
Important:When
filling out forms 1. System Location: JUN 12 2025
on the computer,
use only the tab 1601 SALEM ST
- - --- ...... __
key to move your Address __.
cursor-do not NORTH ANDOVER MA Healt
use the return --- - ...._.... . �
key.
Cityri owrr State ip
2. System Owner:
MATHEW MERRILL
Name —
/Bl1tlR
Address(if different from location)
-- ...-_. —_ -
City/Town State Zip Code
Telephone Number
B. Pumping Record ____.._._..
5/22/25 1500
1. Date of Pumping __.. . _. 2. Quantity Pumped:
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 were disposed:
GLSD
5/22/25
Si n..." re' ..... � ......_.. . _ _.
g f au er Date
�n __ ..... ......... ...........
ature —
g of Receiving Facility(or attach facility receipt) Date
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