HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 125 JOHNNY CAKE STREET 5/1/2026 Commonwealth of Massachusetts Town, of Nodh Andover
City/Town of NORTH ANDOVER
System Pumping Record MAY 13 2026
Form 4
DEP has provided this form for use by local Boards of Health. Other fs.r
information must be substantially the same as that provided here. Be-Un I g'XtrA§%,4ft6 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,
use only the tab 125 JOHNNY CAKE
............... .............. ........... ----——-----------------------—-------------------—-----
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
use the return
key. City/Town -State Zip Code
VQ 2. System Owner:
MARK WEBSTER
Name
ration
--------------------------
Address(if different from location)
City/Town State Zip Code
Telephone-Number
B. Pumping Record
1. Date of Pumping ............
5/1/26 .... 2. Quantity Pumped: 1500____ _
Date- ---- Gallons
3. Component: ❑ Cesspool(s) Z Septic Tank ❑ Tight Tank F1 Grease Trap
R Other(describe): --——-----------------------------
4. Effluent Tee Filter present? ❑ Yes r-1 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:
'GLS .
-------------
.........
5/1/26
;SiatC—u-4�of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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