HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 38 WELLINGTON WAY 7/28/2025 Town of North Andover
Commonwealth of Massachusetts
City/Town of NORTH ANDOVER
AUG 112025
System Pumping Record
Form 4
Health Deparlrngut�e "DEP has provided this form for use by local Boards of Health. Other forms may e used; e
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 CM R 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 38 WELLINGTON WAY
.............. ......................----................ --------------- ------------------......
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
usethe return ....................... .................................... .......... ........................ .............................
key. City/Town State Zip Code
2. System Owner:
JAMES SCARPONE
Name
a m-e .............. ....... -------------—.1...............................
reurdn
Address(if different from location)
............................... .............--------------------------- ...................... —------------------
City[Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping .7/28/25 2. Quantity Pumped: 1500
Date Gallons
3. Component: F-1 Cesspool(s) Z Septic Tank [I Tight Tank F-1 Grease Trap
Fj Other(describe): -- -.1...........
4. Effluent Tee Filter present? M Yes El 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
-CFO-m-piany-
7. Location whexac7tents were disposed:
GLSD
7/28/25
....................................... ....................... ........................... .................
Signature of Hauler Date
- " v-" - --- - ----- - --- -—----- - ------Receiing Facility(or attach facility Date
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