HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 36 EVERGREEN DRIVE 11/10/2025 Commonwealth of Massachusetts TOWn Of North Andover
City/Town of NORTH ANDOVER
System Pumping Record NOV 10 2025
Form 4
DEP has provided this form for use by local Boards of Health. Other formkil"111h form, dVeft P o u r
information must be substantially the same as that provided here. Before using this
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 36 EVERGREEN DRIVE
. ...... ...... ............................................................................. ................ ............... ....................................
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
use the return ................................
key. City/Town State Zip Code
2. System Owner:
MARIA MEYER
Name
retdn
.......... ........................... ...........................................................
Address(if different from location)
Zip Code
—S State t e- . ...... -- -------
Telephone Number
B. Pumping Record
10/16/25 1500
1. Date of Pumping bate - 2. Quantity Pumped: Gallons
3. Component: F-1 Cesspool(s) 0 Septic Tank F-1 Tight Tank Ej Grease Trap
El Other(describe): --------------- ........................--.......... ...................
4. Effluent Tee Filter present? ❑ Yes El No If yes, was it cleaned? El Yes ❑ No
5. Observed condition of component pumped:
GOOD CONDITION
6. System Pumped By:
JAY CURRIER H79406
.. ..... .........-1111-1--1-------------- ... ............ . ....... ....... .....I
Name Vehicle License Number
J'S SEPTIC & DRAIN
Company
7. Location w re ontents re osed:
GLSD
...................... ............------ ........
-10/16/25
Signature of Hauler Date
-11 1.11.1---------------- ................
nature of Receiving Facility(or attach facility receipt) Date
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