HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 75 FOSTER STREET 10/20/2025 1�\ Commonwealth of Massachusetts
................................... Town of North Andover
City/Town of NORTH ANDOVER
4 System Pumping Record Form 4 OCT 2 0 2025
DEP has provided this form for use by local Boards of Health. Pt C r Qws=4�4the
information must be substantially the same as that provided he ck 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 75 FOSTER ST ............... ............. ............................ -------.......................
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
use the return key. City/Town State Zip Code
2. System Owner:
RYAN WOUIVIN
Name
Address(if different from location)
City/Town State Zip Code
Y6i-ep--h-o-n--e- Nu---m---b--e-r- —------ ------------
B. Pumping Record
1. Date of Pumping 10113/25 2. Quantity Pumped: 1000
Date Gallons
3. Component: El Cesspool(s) Z Septic Tank F-1 Tight Tank F-1 Grease Trap
F-1 Other(describe):
4. Effluent Tee Filter present? ❑ Yes E] No If yes, was it cleaned? ❑ Yes Fj 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
10/13/25
——--------
Signatur f au er Date
signature ncl
� ------ofRe-c eiving'--Facility(or attach facility receipt) Date
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