HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1423 SALEM STREET 7/31/2025 Commonwealth of Massachusetts Town Of North Andover
City/Town of NORTH ANDOVER
AUG 112025
System Pumping Record
kq Form 4 Health Depaltme%
DEP has provided this form for use by local Boards of Health. Other forms may be used, bu he
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
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 1423 SALEM ST
.................... ....................................... --------.................................................... ............
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
key.
use the return City/Town -State ---- Zip Code
2. System Owner:
ISABELLE INGRAM
'Name
Address(if different from location)
------------................................................................................................................ ............................. ..........................
State Zip Code
Telepho'ne,....Number --
B. Pumping Record
1. Date of Pumping 7/31/25 2. Quantity Pumped: 1500 ..........
Date Gallons
3. Component: F-1 Cesspool(s) E Septic Tank F-1 Tight Tank F-1 Grease Trap
R Other(describe): ........ ...............................
4. Effluent Tee Filter present? R Yes R No If yes, was it cleaned? R 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 wher nts were disposed:
GLSD
---------------
7
�S"" ----
7/31/25
Signature' ''' 'of'Hauler --------------- ate
7p- --- - - — ................
Siature of Receiving Facility(or attach facility receipt) Date
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