HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 412 SALEM STREET 11/24/2025 �L\ Commonwealth of Massachusetts Town of North Andover
..............
City/Town of NORTH ANDOVER
System Pumping Record DEC - 8 2025
Form 4
DEP has provided this form for use by local Boards of Health. OM(ph# PePOA c his fc!(WAhe
information must be substantially the same as that provided her e ore using , 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 412 SALEM ST
............. ............
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
usethe return .......... ........................................ ................. ---------- -------------------------------
key. City/Town State Zip Code
2. System Owner:
PETER FRASER
.. .
Name ..... .........................
reran
........................... ----------------- --------------
.............. ...................................-
Address(if different from location)
State Zip Code
- -—------- . ...............
—Telephone Number
B. Pumping Record
1. Date of Pumping .11/24/25 2. Quantity Pumped: .1500
-Date - - - --------- Gallons
3. Component: r-1 Cesspool(s) Z Septic Tank El Tight Tank ❑ Grease Trap
F-1 Other(describe): ............... ...........................
4. Effluent Tee Filter present? ❑ Yes 0 No If yes, was it cleaned? E] Yes ❑ No
5. Observed condition of component pumped:
GOOD CONDITION
.................... . ............... ----------- .........I..........
6. System Pumped By:
JAY CURRIER H79406
.. ........................... ---—----------------------------------- ..............—---------------------- .................................-
Name Vehicle License Number
J'S SEPTIC & DRAIN
Company-----------
7. Location where contents were disposed:
GIL
---------...... —----------- ........ . ...... --------------------------- - --------------
'71
11/24/25
gnature of Hauler Date
-Signature- -------- -------------------- .........................- - ------ ..- - . ......---- .........-------- .... .. ... .......... ........ ................. -------------
of Receiving Facility(or attach facility receipt) Date
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