HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 1049 SALEM STREET 12/16/2025 �L\ Commonwealth of Massachusetts Town of North Andover
..........
City/Town of NORTH ANDOVER
System Pumping Record FEB -t 2026
Form 4
DEP has provided this form for use by local Boards of Health. Other+ie4#% k9wartm"t
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 -1 049-SALEM RD -------------- - —---------------------------------------------.....
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
use the return City/Town ................
key. State ............... Zip Code ------
2. System Owner:
LE CHANEY
- ------ - ----------
Name
renan
-Address'('if different fromlo—ca—tion)--
ty/Town State Zip Code
Telephone Number
------..........
B. Pumping Record
1. Date of Pumping 12/16/25 2. Quantity Pumped: 1875
Date - - Gallons
3. Component: ❑ Cesspool(s) E Septic Tank F-1 Tight Tank M Grease Trap
F-1 Other(describe): ---- 11-11111----------—----------............---------—--------------___- ............ ..............---------.......... ............
4. Effluent Tee Filter present? Ej Yes R No If yes, was it cleaned? Yes ❑ No
5. Observed condition of component pumped:
GOOD CONDITION
. ................................. ........... ...........
6. System Pumped By:
JAY CURRIER H79406
- ---..............— -
Name Vehicle License Number
TS SEPTIC & DRAIN
Company
7. Location ere contents were disposed:
GL
12/16/25
..........
g g
nature of Hauler Date
-- --------------- ---------- ................. --------------- ....................
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc-11/12 System Pumping Record-Page 1 of 1