HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 40 DUNCAN DRIVE 4/7/2026 Commonwealth of Massachusetts
Cit /Town of North Andover
System Pumping Record
Form 4
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 CIVIR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, 40 Duncan Drive
use only the tab
key to move your Address
cursor-do not North Andover MA 01845
use the return City/Town State Zip Code
key.
2. System Owner:
VQ Mottolo, Lara
Name
Address(if different from location)
City/Town State Zip Code
917-312-1279
Telephone Number
B. Pumping Record
1. Date of Pumping Date 4/7/26 2. Quantity Pumped: 2000
Gallons
3. Component: F-1 Cesspool(s) FE-1 Septic Tank F-1 Tight Tank F-1 Grease Trap
F-1 Other(describe):
4. Effluent Tee Filter present? FE-1 Yes F-1 No If yes, was it cleaned? Yes F-1 No
5. Observed condition of component pumped:
good
6. System Pumped By:
Fernando Costa 5733A
Name Vehicle License Number
Service Pumping&DRain
Company
7. Location where contents were disposed:
Greater Lawrence Sanitary District
i�M*4t� r"6v-� 4/7/26
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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