HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 7 OLYMPIC LANE 8/11/2025 Commonwealth of Massachusetts Town of*rttl 14nUOVer
City/Town of NORTH ANDOVER
System Pumping Record AUG
Form 4 272025
DEP has provided this form for use by local Boards of Health. Other forms/460th's-4 but the
information must be substantially the same as that provided here. Before using this X10,Par",-vmur
local Board of Health to determine the form they use. The System Pumping Record must be subm, t Wto
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 7 OLYMPIC LANE
. - ----------------------- ............... ........ ............ ------ -----------
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
usethe return --------------- -------------------------- ............... ------------
key. City/Town State Zip Code
2. System Owner:
MELIS SA GENE
Name
Address(if different from location-)-
-City/Town w---n---- -------------------------- —State--- Zip Code
Telephone----- - —Number
- --
B. Pumping Record
8/11/25 1500
1. Date of Pumping bate 2. Quantity Pumped: -G......a lion.s .................
3. Component: r-1 Cesspool(s) M Septic Tank R Tight Tank R Grease Trap
ROther(describe): I 1 1-1-1----------- .....................................................
4. Effluent Tee Filter present? E Yes El No If yes, was it cleaned? Yes R No
5. Observed condition of component pumped:
GOOD CONDITION
------------- -------------------...................-............................. .............. --------I. .............. ------------------ ..................... ------------------- ..........
6. System Pumped By:
JAY CURRIER H79406
-Name — -- -— ----------- ---------- Vehicle
J'S SEPTIC & DRAIN
Company
7. Location w q tents were disposed:
G LSD
8/11/25
..............
Signature of Hauler bate-Signature-- of Receiving Facility(orattach facility-- - receipt) --Date-
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