HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 2350 TURNPIKE STREET 9/5/2025 Commonwealth of Massachusetts Town off Andover
City/Town of NORTH ANDOVER
System Pumping Record
...... Form 4 SEp 16 2025
DEP has provided this form for use by local Boards of Health. Other forms may be use
information must be substantially the same as that provided here. K&OA %rc),eipla,w1u9twith 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 -City/Town -State Zip Code
key.
wo 2. System Owner:
NO- MID OFFICE PARK-A
........................................................................................................................ .......................................................................
Name
rearm
Address- - - (if different'from-location)
City/Town Zip Code
Telephone.-Number
B. Pumping Record
1. Date of Pumping 9/5/25 2. Quantity Pumped: 1500
Date Gallons
3. Component: El Cesspool(s) Z Septic Tank El Tight Tank ❑ Grease Trap
F-1 Other(describe):
4. Effluent Tee Filter present? [:1 Yes ❑ No If yes, was it cleaned? M Yes ❑ No
5. Observed condition of component pumped:
-GOOD CONDITION —----- —-----
6. System Pumped By:
JAY CURRIER H79406
Na-me Vehicle License Number
_J'S SEPTIC & DRAIN
Company
7. Location where contents were disposed:
GLSD
9/5/25
§S-ii-g-febotoeure of-Hauler Date
Signature-o-fReceiving Facility- _(o-r-attach-facility receipt) Date
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