HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 10 COLONIAL AVENUE 4/3/2026 Commonwealth of Massachusetts
Town ()f Wh
City/Town of NORTH ANDOVER Andover
System Pumping Record
Form 4 MAY 13 Z026
DEP has provided this form for use by local Boards of Health. Other forms may be ud,.bu the
information must be substantially the same as that provided her iHl�*k#Wp6phaff , lick 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 10 COLONIAL RD
------------ —--------
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
use the return - ----------- ... ......... - ----------
key. CityfTown State Zip Code
2. System Owner:
DAN GILL
-Na-meaetwn
-
---- --------------- . ........
Address(if different from location)
-
City/Town —State--- Zip Code
Telephone-Number-
B. Pumping Record
1. Date of Pumping 4/3/26 2. Quantity Pumped: 1500 -------------- ......
Date Gallons
3. Component: El Cesspool(s) ® Septic Tank F-1 Tight Tank 0 Grease Trap
❑ Other(describe): ------------ --...............------ ----------------- -—---------
4. Effluent Tee Filter present? E Yes [I No If yes, was it cleaned? E Yes ❑ No
5. Observed condition of component pumped:
GOOD CONDITION
111---------- -----------11-------— ----------- --------- ........ -------------
6. System Pumped By:
JAY CURRIER H79406
--------------- ------ .......... ..........
Name Vehicle License Number
TS SEPTIC & DRAIN
Company
7. Location where contents were disposed'.
GL§PK) ....................... - ------
0�1 .. 4/3/26
d4 ......... —--------- .........
-Sig�—Um-of--Hauler Date
.............. -----—-----------
Signature of Receiving Facility(or attach facility receipt) Date
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