HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 5 CHRISTIAN WAY 6/13/2025 Commonwealth of Massachusetts Town ofNofth Andover
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System Pumping Record ~UN 2 6 2025
Form 4
QEP has provided this form for use by local Boards cfHealth. Othe44i08/b�yD
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 31OCK8R15351.
A. Facility Knfm.r00@kt~on
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 5CHR|8T|AN WAY
key m move your xuumas
cursor'do not
N[}RTHANOC}VER VIA 01845
use mommm
key. City/Town State Zip Code -
�
2. Syotenn(�vvner
�--� MIKE DUNN
Name
T61ephone Number
B. Pumping Record
6/13/25 1500
1. Date ofPunnp|ng 2. Quantity Pumped:
3. Component [l Cesspool(s) Z Septic Tank El Tight Tank Fl Grease Trap
[] Other(describe):
4� Effluent Tee Filter present? F-1 Yes [I No |f yes, was itcleaned? Yes No
5. Observed condition of component pumped:
GOOD CONDITION -
G. System Pumped By:
JAY CURRIER H79408
Name Vehicle License NumbW
J'S SEPTIC & DRAIN
mpany
7 Location where contents were disposed:
6/13/25
/nature of Hauler Date
Signature of Receiving Facility(or attach facility n,oc'pV Date