HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 71 OLYMPIC LANE 8/8/2025 �L\ Commonwealth of Massachusetts Town of North Andover
............
City/Town of NORTH ANDOVER
System Pumping Record AUG 14 2025
Form 4
DEP has provided this form for use by local Boards of Health. he
""I t '
information must be substantially the same as that provided here. Before gA%i fteck 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 CIVIR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab -71-01LYMPI.0 LANE .................... ........... -------........................... ....... ..........................
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
use the return
key. City/Town State Zip Code
2. System Owner:
SPENCER MARTIN
Name
. ....................a._.........._..................................................
Address(if different from location)
--------------------
-Citiao wn State Zip Code
Telephone- um'b'e'—r ----
B. Pumping Record
1. Date of Pumping 8/8/25 2. Quantity Pumped: 1000
DateGallons
3. Component: ❑ Cesspool(s) Septic Tank R Tight Tank El Grease Trap
f-1 Other(describe): .......................... .............
4. Effluent Tee Filter present? ❑ Yes El No If yes, was it cleaned? F-1 Yes ❑ No
5. Observed condition of component pumped:
GOOD CONDITION
............... ..................
6. System Pumped By:
JAY CURRIER H79406
Name Vehicle L i oe n-s e'-Number
J'S SEPTIC & DRAIN
Company
7. Location whearroont is were disposed:
GLSD
8/8/25
Signature of Hau-er-- Date
Signature of Receiving Facility(or attach facility receipt)------------ -Date-
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