HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 101 ABBOTT STREET 10/10/2025 Commonwealth of Massachusetts Town of Not Andover
City/Town of NORTH ANDOVER
K
System Pumping Record OCT 10 2025
Form 4
DEP has provided this form for use by local Boards of Health. Other UwAk awartment
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,
use only the tab 101 ABBOTT 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:
MANNICRUZ
Name
rnddn
Address—(if'different-from location-)-------------------
---------------------------- --------
I�ti w--n- ......... State Zip Code
-Telephone-Number --------------
B. Pumping Record
1. Date of Pumping 10/3/25 2. Quantity Pumped: .100-0
-6ate -- Gallons
3. Component: F-1 Cesspool(s) Z Septic Tank F-1 Tight Tank M Grease Trap
F-1 Other(describe): .. ............. .......................................11-111 --
4. Effluent Tee Filter present? El Yes D No If yes, was it cleaned? Fj Yes M No
5. Observed condition of component pumped:
GOOD CONDITION
6. System Pumped By:
JAY CURRIER H79406
Nam e ------- - ------—--------------------------- -V-e---h-i--c-le----L-"i-c-e-n-se-Nu-mb'e"r""------- - -----------
J'S SEPTIC & DRAIN
................................
Company
7. Location where contents were disposed:
�qLSV-1-
10/3/25
Sig ure of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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