HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 1055 SALEM STREET 11/13/2025 Commonwealth of Massachusetts Town of NoO Ardover
City/Town of NORTH ANDOVER
NOV 19 System Pumping Record
2025
Form 4
DEP has provided this form for use by local Boards of HeaItP@AAQ9-' ay',"!9Mt 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,
1055 SAL
use only the tab EM ST
---------------- ..................... — -------------------.............. ------
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
usethe return -.............------ ---------------------- ............. .....-..................... -......................... ..........
key. City/Town State Zip Code
OQ2. System Owner:
JOSE RODRQUEZ
........................ .................. ------.................................
Name
ream
..................— ------ ....... .................--—----------
Address(if different from location)
- iti/town - ------- ---------- -1 State 11- I ...............------------ Zi-p--Code
, ,
Telephone-- — .........
...........
Number
B. Pumping Record
11/13/25 1500
1. Date of Pumping Date 2. Quantity Pumped: Gallons .........................
3. Component: R Cesspool(s) Septic Tank R Tight Tank R Grease Trap
ROther(describe): ------------------------------- -1-11.1111.1---.............................
4. Effluent Tee Filter present? Z Yes El No If yes, was it cleaned? Z Yes R No
5. Observed condition of component pumped:
GOOD CONDITION
----------- -------------1............... .................. ............ ---------------- ..........................................................
6. System Pumped By:
JAY CURRIER H79406
-------
Name Vehicle License Number
J'S SEPTIC & DRAIN
Compan-y- - -----
7. Location r contents were disposed:
GLSD
---------- . .......... ------------ -------
11/ -----------
13/25
-w .............
Signature of Hauler Date
.......................
f .............. ..........................
------------ -------------------------
ReceivingSignature
Facility(or attach facility receipt) Date
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