HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 55 TIFFANY LANE 3/20/2026 Commonwealth of Massachusetts Town of Norl:h Andover
D.
City/Town of NORTH ANDOVER
System Pumping Record APR - 6 2026
Form 4
DEP has provided this form for use by local Boards of Health. Othe"e*t400PMtMtq#
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 55 TIFFANY LANE
..........
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
use the return key. Cityrrown State Zip Code
2. System Owner:
MARY STEELE
Name
Address—(if different from location)"
cityrrown State Zip Code
Telephone NumberB. Pumping Record
3/20/26 1500
1. Date of Pumping Date .............. 2. Quantity Pumped: Gallons
3. Component: El Cesspool(s) Z Septic Tank F-1 Tight Tank M Grease Trap
Fj Other(describe): ........... ..................... ...........
4. Effluent Tee Filter present? [--1 Yes ❑ No If yes, was it cleaned? ❑ Yes F-1 No
5. Observed condition of component pumped:
GOOD CONDITION
6. System Pumped By:
JAY— .. ....._.._.....I..-.--- ----
CURRIER H79406 ..........
—- --
'-Name Vehicle License Number
J'S SEPTIC & DRAIN
Company
7. Location whe contents were disposed:
GLSD ......
3/20/26
------- .....-—---------- ............................................. .............. ...........
g ure of Hauler Date
—----------------
ignature of Receiving Facility(or attach facility receipt) Date
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