HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 980 WINTER STREET 6/19/2025 Town
Commonwealth of Massachusetts lown ®f North Andover
City/Town of NORTH ANDOVER
JUN 2 6 2025
System Pumping Record
Form 4
Health Department
DEP has provided this form for use by local Boards of Health.
alth. 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 CIVIR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 980 WINTER ST ------ ------
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
use the return ------ .......... ............... ........... ------- .....................
key. City/Town State Zip-Code
40--h
VkA 2. System Owner:
NICOLE DONEGAN
Name
renxr
...................
Address(if different from location)
............ ...........
City/Town State Zip Code
...........................................
Telephone Number
B. Pumping Record
1500
1. Date of Pumping 6/19/25 ----------- 2. Quantity Pumped:
-b-ate--- Gallons-----
3. Component: M Cesspool(s) Septic Tank r_1 Tight Tank F-1 Grease Trap
ROther(describe): 1------------------------------------------ ...........................................I-----------
4. Effluent Tee Filter present? r_1 YesE] No If yes, was it cleaned? M 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;7h contents were disposed:
GLSD
------------------
6/19/25
..................................................................... .............
-or
Sigre of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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