HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 770 BOXFORD STREET 11/13/2025 Commonwealth of Massachusetts Town of Nofth Andover
City/Town of NORTH ANDOVER
System Pumping Record NOV 19 2025
Form 4
DEP has provided this form for use by local Boards of Health. Other derAMaPA944,r"ffit
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 770 BOXFORD ST
11111111............................I-,.................. .................. ------------ - ------------- ............ ..................-
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
use the return ............- ---—---------------- ......... ....... ................
key. City/Town State Zip Code
2. System Owner:
NELSA ESTRELLA
Namewren
Address(if different from location)
------------------------ .......................... -------------City/Tawn State Zip Code
Telephone Number
B. Pumping Record
11/13/25 2. Quantity Pumped: 1500
1. Date of Pumping Date G-allon-s-,
3. Component: ❑ Cesspool(s) Z Septic Tank R Tight Tank F-1 Grease Trap
ElOther(describe): ------------------------ ---------- ...................................................... -------------
4. Effluent Tee Filter present? El Yes 0 No If yes, was it cleaned? F-1 Yes F-1 No
5. Observed condition of component pumped:
GOOD CONDITION
............................- ----------------------
6. System Pumped By:
JAY CURRIER H79406
-Nam-"e------ -,- -- - --- - - - -V-e--h-ic-le-License e--nse Number
J'S SEPTIC & DRAIN
Company
7. Location where-contents were disposed:
�GLS D
Ile
414f aA-,4
Sig Hauler Date
------------ —------- -......----
Signature of Receiving Facility(or attach facility receipt) Date
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