HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 595 BOXFORD STREET 7/28/2025 Commonwealth of Massachusetts N
City/Town of NORTH ANDOVER
System Pumping Record
Form 4 4
DEP has provided this form for use by local Boards of Health. Other,forms m be used, but the
information must be substantially the same as that provided here. Beforid'bti4fhM heck with your
local Board of Health to determine the form they use. The System Pumping Record mu submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CIVIR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 595 BOXFORD ST
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
use the return City/Town State Zip Code
key.
VQ 2. System Owner:
NICK STANZIONE
Name
----------
'Address(if different from location)
State Zip Code
Number ...... .........................
-Telephone —
B. Pumping Record
1. Date of Pumping 7/28/25 2. Quantity Pumped: 1000
Date Gallons
3. Component: El Cesspool(s) Z Septic Tank ❑ Tight Tank F-1 Grease Trap
F-1 Other(describe): ................
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? M Yes El No
5. Observed condition of component pumped:
GOOD CONDITION
6. System Pumped By:
JAY CURRIER H79406
Warne ----- - Vehicle License Number
J'S SEPTIC & DRAIN
Company
7. Location where contents were disposed:
GLSD
b-1 7/28/25
Signat re 041gry Date
Sign ure of Receiving Facility(or attach facility receipt) Date
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