HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 1447 SALEM STREET 12/5/2025 Commonwealth of Massachusetts Town Of lvorm 4ndover
City/Town of NORTH ANDOVER
'DEC I
System Pumping Record
Form 4 Health De
DEP has provided this form for use by local Boards of Health. Other forms maAR the
information must be substantially the same as that provided here. Before using this,form, c eck 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 .1447 SALEM ST ---—------------------------------—...... ...............
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
use the return - ----
key. City/Town State Zip Code
2. System Owner:
JOE VALINCH
Name
Address(if different from location)
State Zip Code
-----------------------------
Telephone Number
B. Pumping Record
1215/25 1000
1. Date of Pumping ........................ 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) Z Septic Tank R Tight Tank R Grease Trap
R Other(describe):
4. Effluent Tee Filter present? R Yes R No If yes, was it cleaned? R 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
ICompany—
7. Location where contents were disposed:
GLSD
12/5/25
Sign ure auier Date
.0
...........- —---------
Sig ture of Receiving Facility(or attach facility receipt) Date
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