HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 2350 TURNPIKE STREET 9/5/2025 (3) ICN Commonwealth of Massachusetts Town of North Andover
...-...............
W City/Town of NORTH ANDOVER
System Pumping Record SEP 16 2025
-❑ Form 4
DEP has provided this form for use by local Boards of Health. OtI4q4XQAPa0Wnte
information must be substantially the same as that provided here. Before using this form, check 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 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:
SCP Co.
.................................... ........................................ ------------------------ .................
Name
............................................ .................................. ---------------- ........... -------------
Address(if different from location)
State Zip Code
Telephone NumberB. Pumping Record
1. Date of Pumping 9/5/25 .........------ 2. Quantity Pumped: 1.5001.............
pateGallons
3. Component: El Cesspool(s) Z Septic Tank Fj Tight Tank n Grease Trap
F-1 Other(describe): ------- —-------- ............-.-................ ..................
4. Effluent Tee Filter present? El Yes R No If yes, was it cleaned? ❑ Yes Ej No
5. Observed condition of component pumped:
GOOD CONDITION
--l-1-111111-1.............................................I................ - -------- —----------............- ---------- ..........
6. System Pumped By:
JAY CURRIER H79406
.....................................
Name. ........... Vehicle License Number
J'S SEPTIC & DRAIN
Company --
7. Location where contents were disposed:
GLS
.................. .......... ....... --------- --—---------- ........... .............
9/5/25
--------- ... ........
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nature f Hauler e4q"7----
,.Aignature---o------H-- Date
Signature of Receiving Facility(or attach facility receipt) Date
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