HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 1365 SALEM STREET 11/13/2025 Commonwealth of Massachusetts Town of Noo��
City/Town of NORTH ANDOVER
NOV 19 2025
System Pumping Record
Form 4
Health Departrn,,.,,,1L
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 1365 SALEM ST
------------------ ........... . ......................... ............
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
use the return ..................
key. City/Town Zip Cade
-------------
2. System Owner:
HELEN CUNNIFF
.................... --------------- ............................................. ------------
Name
ream
Address"(if,different from- location)----
-Ciit-y)t'o'w"n ............ -State Zip Code
' .........
"phone Number
B. Pumping Record
11/13/25 1500
1. Date of pumpingDate 2. Quantity Pumped: Gallons
3. Component: F-1 Cesspool(s) Z Septic Tank [] Tight Tank E] Grease Trap
❑ Other(describe): .-1--.1.1 ---—---------------------------------------------------- ........... ................... ---..................
4. Effluent Tee Filter present? R Yes El No If yes, was it cleaned? F-1 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
-------------
/13/25
...................
. . ..........
r --A- 7A --
SiSig r Date
—----------- -------------------11-1---------------------------------- ---------- --------...--
Signature
;/of Receiving Facility(or attach facility receipt) Date
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