HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1565 SALEM STREET 7/29/2025 Commonwealth of Massachusetts Town Of NO*AndOVer
City/Town of NORTH ANDOVER
System Pumping Record Form 4 AUG 12025
DEP has provided this form for use by local Boards of Health.Re ftn4 may be used, but the
information must be substantially the same as that provided here. 6 "' heck with your
local Board of Health to determine the form they use. The System Pumping Record fe 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 1565 SALEM ST .................................................-—-----------------------—--------
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
use the return City/Town State Zip Code
key.
VQ 2. System Owner:
ERIC AMBRETTE
Name
ream
1 _____
Address(if different from location)
City/Town State Zip Code
Telephone-
B. Pumping Record
7/29/25 1500
1. Date of Pumping 2. Quantity Pumped: G.............-__—____.-_._.._._._-___--
Date
3. Component: El Cesspool(s) Z Septic Tank M Tight Tank F-1 Grease Trap
F-1 Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes R 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
7/29/25
Signat of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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