HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 2200 TURNPIKE STREET 11/10/2025 Commonwealth of Massachusetts Of lvorth4ndover
City/Town of NORTH ANDOVER
TVJ System Pumping Record Nov 10 2025
Form 4
DEP has provided this form for use by local Boards of Health. Other forms MWW 4*0 t he
r
information must be substantially the same as that provided here. Before using this far At our
local Board of Health to determine the form they use. The System Pumping Record must be subumil6d 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 2200 TURNPIKE RD ...... ............
key to move your Address
cursor-do not NORTH ANDOVE MA 01845
use the return ------
key. City/Town State Zip Code
2. System Owner:
LARRY TRACEY
- . ................................................... ..--........._..............................-
Name
. ........................
Address(if different'fn3rr location)
------ .......---
i�ir-o—wn------- —Sta-t—e - --Z--ip---C—ode----
-Telephone, N---u"m b—er -------—--------
B. Pumping Record
1. Date of Pumping .10/29/25 ----------............ 2. Quantity Pumped: .1000
Date Gallons
3. Component: ❑ Cesspool(s) E Septic Tank F-1 Tight Tank El Grease Trap
F-1 Other(describe): —------------....................... ..............
4. Effluent Tee Filter present? F-1 Yes M No If yes, was it cleaned? F-1 Yes M 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. Lola w ere contents were disposed:
----------------- .......... .......... .............. .
..............
..........................
10/29/25
Signature of Hauler Date
. ..........
Signature of Receiving Facility(or attach facility receipt) Date
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