HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 101 SHERWOOD DRIVE 8/22/2025 "r-
Commonwealth of Massachusetts I own of North Andover
City/Town of NORTH ANDOVER
. ....... AUG 2 7 2025
System Pumping Record
Form 4
Health Depart
DEP has provided this form for use by local Boards of Health. Other forms may be used, 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 101 SHERWOOD DRIVE
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
use the return ------ ...............
key. City/Town State Zip Code
2. System Owner:
ANDREW SWIM
Name
Address(if different from location)
City/Town State Zip Code
T-
elephone Number
B. Pumping Record
8/22/25 1500
1. Date of Pumping 2. Quantity Pumped: ............... -----------
-Da-te- Gallons
3. Component: F-1 Cesspool(s) Z Septic Tank ❑ Tight Tank ❑ Grease Trap
F-1 Other(describe): .......... .................. .............
4. Effluent Tee Filter present? El Yes 0, 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
-Company
7. Location where contents were disposed:
GLSD —------
8/22/25
---------- ------------------
_S16 n--a--t- -
u 6- Date
----------------
-§igna-t e of Receiving Facility(or attach facility receipt) Date
t5form4.doc-11112 system Pumping Record-Page 1 of 1