HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 218 LACY STREET 8/22/2025 Town of North Andover
Commonwealth of Massachusetts
City/Town of NORTH ANDOVER AUG 2 7,2025
System Pumping Record Form 4 Health Department
DEP has provided this form for use by local Boards of Health. 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 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 218 LACEY ST
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
use the return ..................... ------------------
key. City/Town State Zip Code
2. System Owner:
TROY MORGAN
Name
ream
Address(ifdifferent-from---location--)
--—----- ----------
aty�)fow ----
n- - State Zip Code
Tel.e-phone Numb-er
B. Pumping Record
8/22/25 1500
1. Date of Pumping Date'------ — 2. Quantity Pumped: Gallons
3. Component: F-1 Cesspool(s) Z Septic Tank F-1 Tight Tank R Grease Trap
F-1 Other(describe): .................
4. Effluent Tee Filter present? Z Yes F No If yes, was it cleaned? Z Yes El No
5. Observed condition of component pumped:
GOOD CONDITION
------- ----------
6. System Pumped By:
JAY CURRIER H79406
Name Vehicle License Number
J'S SEPTIC & DRAIN
Gompa--n-y-----------
7. Locati ere contents were disposed:
GL D .............. .............
ov/- --—-------------
L�00-
8/22/25
Signature of Hauler Date
- ------------ —-------
ignature of Receiving Facility(or attach facility receipt) Date
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