HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 224 CARLTON LANE 5/4/2026 IL Town of NMh Andover
Commonwealth of Massachusetts
City/Town of NORTH ANDOVER
MAY 13 2026
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may beLUR"tnt
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,
use only the tab 224 CARLTON LANE —-- ------
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
use the return City/Town State Zip Code
key.
2. System Owner:
GREG HUGHES____________
Name
Address f different from location)
City/Town.......... State Zip Code
TelephoneNumber-------
B. Pumping Record
1. Date of Pumping 5/4/26 2. Quantity Pumped: 1500
Date Gallons
3. Component: El Cesspool(s) E Septic Tank F-1 Tight Tank M Grease Trap
Fj Other(describe): —--------.......
4. Effluent Tee Filter present? R Yes M No If yes, was it cleaned? ❑ Yes M 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 re contents were disposed:
GLS
-----............ 5/4/26
nature of Hauler
Date
Signature of Receiving Facility(or attach facility receipt) Date
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