HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 177 CARLTON LANE 11/13/2025 - 11�\- Commonwealth of Massachusetts TOW17 Of North
. ................. Andove
City/Town of NORTH ANDOVER r
System Pumping Record NOV 19 2025
Form 4
DEP has provided this form for use by local Boards of Health. b used, but the
ofg sg,a y e
information must be substantially the same as that provided here."Be eck with your
local Board of Health to determine the form they use. The System Pumping Record mu 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 177 CARLTON LANE
........................................ ------------------- . ........
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
use the return ................. ................. -Z6i Cade
key. City/Town State
2. System Owner:
BILL LAUZON
Name
aam
........................
Address(if different from location)
-Cityao w- n- -State-,------- -Zip-Code
-
Telephone Number
B. Pumping Record
11/13/25 2. Quantity Pumped: 1500
1. Date of Pumping ...................
Date
- ---- Gallons
3. Component: F-1 Cesspool(s) Z Septic Tank R Tight Tank R Grease Trap
ROther(describe): .............................. --------------------------- .......................... 11111-11111--..........................
4. Effluent Tee Filter present? 0 Yes Ej No If yes, was it cleaned? ❑ Yes ❑ 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:
GL§ ------ ---------------- - --------------
11/13/25
Date
n ure of Hauler
--—------- -- ---------------..........
Signature of Receiving Facility(or attach facility receipt) Date
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