HomeMy WebLinkAboutNA Waste Systems 2 Tanks - Septic Pumping Slip - 210 HOLT ROAD 9/3/2025 Town of North Andover
Commonwealth of Massachusetts I
......... ............. OCT 2X2025
City/Town of North Andover
System Pumping Record
............
Form 4 Health Department
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
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 210 Holt Road
key to move your Address
cursor-do not North Andover MA 01845
use the return
key. City/Town State Zip Code
2. System Owner:
VQ North Andover Waste Systems
Name
ro
Address(if different from location)
City/Town State Zip Code
617-922-5724
Telephone Number
B. Pumping Record
1. Date of Pumping 9/3/25 2. Quantity Pumped: 3500
Date Gallons
3. Component: F Cesspool(s) X Septic Tank n Tight Tank F] Grease Trap
El Other(describe): (2)tanks
4. Effluent Tee Filter present? F-1 Yes F-1 No If yes,was it cleaned? ❑ Yes 0 No
5. Observed condition of component pumped:
both good
6. System Pumped By:
Al Santos 5733A
Name Vehicle License Number
Service Pumping&Drain
Company
7. Location where contents were disposed:
Greater Lawrence Sanitary District
'4z' — 9/3/25 —---------------
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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