HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 76 BOSTON HILL ROAD 6/12/2025 Commonwealth of Massachusetts
- City/Town of NORTH ANDOVER
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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 Aver
Important:When filling out forms 1. System Location: JU'YN
2
on the computer,
use only the tab 76 BOSTON HILL RD
_ -- -- __
key to move your Address
cursor-do not ey
use the return NORTH ANDOVER MA !
key._
City/Town State Zip co
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2. System Owner:
r KEVIN DUBS
Name
seen ALMAMORI
Address(if different from looation)
cit0own State Zip Code
Telephone Number
............. .-........__.__....... ___—.___............................
..._.
B. Pumping Record
1. Date of Pumping 5/30/25 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 were disposed:
GLSD
5/30/25
_ _ ... . _ .......,._ --
Signature ar Date
_- - .......
ignature of Receiving Facility(or attach facility receipt) Date
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