HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 742 BOXFORD STREET 11/19/2025 Commonwealth of Massachusetts Town of AlOrth Andover
City/Town of NORTH ANDOVER DEC
025
System Pumping Record
Form 4 Health L)ePartMe
DEP has provided this form for use by local Boards of Health. Other forms may be used, RuNe
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 CIVIR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 742 BOXFORD ST
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
use the return City/Town State Zip Code
key.
VQ 2. System Owner:
CHRIS HAGERTY
Name —----------- —sam
Address
ddr e s s(if differ ent from location)
-----------
State Zip Code
ie phone Number
B. Pumping Record
1. Date of Pumping 11/19/25 2. Quantity Pumped: 1500
Date Gallons
3. Component: ❑ Cesspool(s) E Septic Tank F-1 Tight Tank El Grease Trap
❑ Other(describe): .....................................................................
4. Effluent Tee Filter present? Fj Yes ❑ No If yes, was it cleaned? E] Yes E] 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
T Location where contents were disposed:
GLSD
-- ----------- ----z 11/19/25
--- -----------------
le,
gn r r- bite
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc-11/12 System Pumping Record-Page 1 of 1