HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 83 CAMPBELL ROAD 10/10/2025 Commonwealth of Massachusetts TOWn of North Andover
City/Town of NORTH ANDOVER
System Pumping Record OCT 10 2025
qq-_f Form 4
DEP has provided this form for use by local Boards of Health. 040ciftno bout he
information must be substantially the same as that provided here. Before using 10 "k 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 83 CAMPBELL RD
......................................................... .......... ...............- —-----.................. ...........
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
usethe return ------------ .............................. ............................... ........................................ .................
key. City/Town State Zip Code
2. System Owner:
LUCY FALLON
----------- ..............
ame
-------------- -------- ............................................................-------------Address(if different from location)
............- State
............ ...........
City/Town ------------ .- e Zip Code
—---------------------------------------------Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped: 1000 ............
Date Gallons
3. Component: Fj Cesspool(s) Z Septic Tank F-1 Tight Tank 0 Grease Trap
F-1 Other(describe): ------------------------------------------------ ----------------------------------------- ............
4. Effluent Tee Filter present? E] Yes E] No If yes, was it cleaned? ❑ Yes Ej No
5. Observed condition of component pumped:
GOOD CONDITION
...............
& System Pumped By:
JAY CURRIER H79406
Name —---------- Vehicle License Number
-.J'.S- SEPTIC
E P T1-1IC 1& DRAIN
- --y-1-.-- .........6ompan .
7. Location where contents were disposed:
GLSD
10/6/25
Sign u Date
Sii a t ure of Receiving Facility(or attach facility receipt) Date
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