HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 2009 SALEM STREET 5/1/2026 Commonwealth of Massachusetts Town of North Andover
City/Town of NORTH ANDOVER
I System Pumping Record
Form 4 MAY 13 2026
DEP has provided this form for use by local Boards of Health. Other forms
information must be substantially the same as that provided here. Before using"hifflorV, 094W"t
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 2009 SALEM ST
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
use the return ........................ ------
key. City/Town State Zip Code
2. System Owner:
JEFF MAKOWSKI
Name
renm
..............
Address(if different from location)
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 5/1/26 --------------- 1500 2. Quantity Pumped: Gallons
3. Component: R Cesspool(s) Z Septic Tank F-1 Tight Tank M Grease Trap
E] Other(describe): .................
4. Effluent Tee Filter present? Z Yes 0 No If yes, was it cleaned? Z Yes D 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:
GLSD
41
5/1/26
Si tore of Hauler ......... ------------------------------------ Date
SignatureFacility(or attach facility receipt) Date
-- 7 -'-'o-f—R—ec-ei-v-i--n--g---
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