HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 1317 SALEM STREET 12/4/2025 Commonwealth of Massachusetts Town of Neh Andover
City/Town of NORTH ANDOVER
....... . ........
DEC 17 Z025
System Pumping Record
Form 4
Health Department
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
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 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 1317 SALEM RD
............. ........----------- -----------
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
use the return ---------------------------- .............
key. City/Town State Zip Code
VQ 2. System Owner:
CHRIS ORLICH
Name
reaan
................................. ............................... .........
Address(if different from location)
..............................-- - -......------ ---------- ............... ......... .......
City/Town State Zip Code
Telephone Number
B. Pumping Record
12/4/25 1500
1. Date of Pumping e- 2. Quantity Pumped: Lallans--
Dat3. Component: R Cesspool(s) Septic Tank ❑ Tight Tank R Grease Trap
❑ Other(describe): ..................... ...................................--.................................
4. Effluent Tee Filter present? R Yes [] No If yes, was it cleaned? R Yes R 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. Location where contents were disposed:
GLSD
.............
12/4/25
......... z .. .........
Siwure of Hauler
Date
Signature......................---------------- -------- -- --------------- ----
of Receiving Facility(or attach facility receipt) Date
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