HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1806 SALEM STREET 10/10/2025 ILA Commonwealth of Massachusetts Town of North Andover
"^ w City/Town of NORTH ANDOVER
w System Pumping Record OCT 10 202
Form 4
DEP has provided this form for use by local Boards of Health. Othjr*AVkPARWrW@1
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 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, 1$06 SALEM ST
use only the tab
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
use the return ____, -----------_.._-- -----
key. City/Town State Zip Code
VG:l 2. System Owner:
ILIR KAVAJA
_ -
Name
eaan
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
10/3/25 1500 Date
1. Date of Pumping ........_.. 2. Quantity Pumped: -Gallons- — _...
3. Component: ❑ Cesspool(s) ® Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): ----
4. Effluent Tee Filter present? ® Yes ❑ No If yes, was it cleaned? ® Yes ❑ 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. Location where contents were disposed:
GLSD
10/3/25
__._ _._.._ -..__..__- ................_. ...-------
Sig ure of Hauler - _ Date
------------------ ---- .......
Signature of Receiving Facility(or attach facility receipt) Date
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