HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 1213 SALEM STREET 11/3/2025 Commonwealth of Massachusetts
City/Town of NORTH ANDOVER N o
Ro
System Pumping Record pv
Form 4
DEP has provided this form for use by local Boards of Health. Other for
information must be substantially the same as that provided here. Be,,,.r tk�Uq rbleg"ith your
9c
local Board of Health to determine the form they use. The System P pnhg5-,bdrdVust 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 1213 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:
WILLIS LARSON
Name
rettrn
Address(if different from location)
-State-------- -Z--i'p' C"'o"'City/Townde
------------------------------------------------ --------
Telephone --------
Number
B. Pumping Record
1. Date of Pumping 11/3/25 2ity Pd: 1500 ...... ..........
Date .................... . Quant Pumped:
Gallons
3, Component: Fj Cesspool(s) Septic Tank R Tight Tank F-1 Grease Trap
El Other(describe):
4. Effluent Tee Filter present? ❑ Yes F-1 No If yes, was it cleaned? ❑ Yes F-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
7. Location where contents were disposed:
GLSD
............. 11/.3/25
Signature Ha ler Date
Signature
iviFn-g6-lF—ac-i-li-t--y-(ora—ttac-h---'f'a c'i'l'ity"-re"c e-ip—t) -Da-t e"
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