HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 93 SUGARCANE LANE 10/20/2025 T.
Commonwealth of Massachusetts I own of North Andover
City/Town of NORTH ANDOVER
OCT 2 0'2025
System Pumping Record
Form 4
Heal
DEP has provided this form for use by local Boards of Health. Other forms may tq
RA,P Aftent
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 93SUGARCANE
----------- ------- -------- -------
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
use the return ................. -_-------- .......___.............
key. CityfTown State Zip Code
2. System Owner:
JOHN SLATTERY
............................................. ------------ ---------------
Name
eaav
__---------- ...................................................................-.............. ............ -------------
Address(if different from location)
.............. -------------------------- — ------------------ ...............
State Zip Code
_Telephone_Number --------------B. Pumping Record
1. Date of Pumping 10/13/25 . .........___ 2. Quantity Pumped: ..1500
Date ----_----_-_ -- . p G'al-lo,n
3. Component: r_1 Cesspool(s) Z Septic Tank F1 Tight Tank ❑ Grease Trap
El Other(describe): .............. -------------
4. Effluent Tee Filter present? ❑ Yes [] No If yes, was it cleaned? 0 Yes r_1 No
5. Observed condition of component pumped:
GOOD CONDITION
--------------------------------------------------------------- ------------------
6. System Pumped By:
JAY CURRIER H79406
--Name 11 I --------------- ----------------- Vehicle License Number 11 - I 11.�ll,�,�.,.'ll""I'll,�'ll""II
J'S SEPTIC & DRAIN
--------_-_
Company
7. Location where contents were disposed:
GLSD
10/13/25
............................... ....... ..................
Signat of Hauler Date
----------------------- ------------ ...............
_S_4nvfureof Receiving Fa__-ci-l-i-t-y'--(,-o-,r---a-t--t-a--c--h"-f"-a-ci-l-it-y---re--c-e-i--p-t-)--- Date
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