HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 9/5/2025 Commonwealth of Massachusetts Town of North Andover
City/Town of NORTH ANDOVER
System Pumping Record SEP 16 Z05
Form 4
DEP has provided this form for use by local Boards of Health. OtherA I Upe t information must be substantially the same as that provided ! C M�ing this'ZV 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 .2350 TURNPIKE RD ..........................
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
use the return
key. City/Town State Zip Code
2. System Owner:
NO- MID OFFICE PARK-B
Name
----
Address(if-different fro-m-io cation-)- - - -------- ------
iiie zipCoa_e __________
f e h—on- ---- —e r -----.............elpe Numb
B. Pumping Record
1. Date of Pumping .9/5/25 .......... 2. Quantity Pumped: 5000
Date Gallons
3. Component: ❑ Cesspool(s) Z Septic Tank El Tight Tank M Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes [:1 No If yes, was it cleaned? Fj Yes F-1 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. Locationontents were disposed:
GLSD
9/5/25--__1—-------
Signature of Hauler Date
of_R f Date
Signature e6eiiving-Fa Facility(or attach facility receipt)
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