HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 205 CAMPBELL ROAD 2/2/2026 'L\ Commonwealth of Massachusetts Town of Nofth AndOver
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City/Town of NORTH ANDOVER
System Pumping Record FEB - 2 2026
Form 4
DEP has provided this form for use by local Boards of Health. &WRMS9,,,god, but the
information must be substantially the same as that provided here. Before L "ck 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 205 CAMPBELL RD
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key to move your Address
cursor-do not NORTH ANDOVER MA 01845
usethe return 111111-------------- - - - ------------------ -----------.................
key. City/Town State Zip Code
2. System Owner:
MIKE O'BRIEN
Name
rerun
Address(if different from location)
State----- -Zip Code
............ .......... . ............. ...............---
Telephone Number
B. Pumping Record
12/17/15 1000
1. Date of Pumping - .ate l�'ll"..,��--.--------�--�.-.,1--�ll-�,-.-11�-- 2. Quantity Pumped: Gallons .............
3. Component: R Cesspool(s) E Septic Tank ❑ Tight Tank F] Grease Trap
F-1 Other(describe): ..............
4. Effluent Tee Filter present? F Yes R No If yes, was it cleaned? E] Yes r-1 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
ompany
7. Location where contents were disposed:
LSD G
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afo4for 12/17/25
----Si ture of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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