HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1590 OSGOOD STREET 6/1/2026 Commonwealth of Massachusetts Town of North Andover
City/Townof North Andover
2026
System Pumping Record JUN 9
Form 4
H - h
DEP has provided this form for use by local Boards of Health. Other forms maeAeii us9e
, &Vnent
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 Jimmy's Pizza- 1595 Osgood Street
-.-....................... ..........
key to move your Address
cursor-do not North Andover MA 01845
use the return .......................... ..............
key. City/Town State Zip Code
2. System Owner:
VQ Larkin&Larkin Development
.......... .......................... ............. ....................... -—--------- ..............
Name
Address(if different' - - -from-- -location)
Cr ty�w.n...........--..........------------------- State- . .............. Zip Code-----------
781-944-7808
Telephone Number
B. Pumping Record
1000
1. Date of Pumping 6/1/26- - - 2. Quantity Pumped: ----.....................................
Date Gallons
3. Component: R Cesspool(s) Septic Tank R Tight Tank R Grease Trap
ROther(describe): .......... ...............---..............................--................ ......
4. Effluent Tee Filter present? F] Yes F] No If yes, was it cleaned? R Yes F] No
5. Observed condition of component pumped:
d
goo
- - ------------- .................. ...........--............... ...............
6. System Pumped By:
Andrew Holland 5733A
Na—Me Vehicle--- License N um-b-e-r—
Service Pumping&Drain
Company
7. Location where contents were disposed:
Greater Lawrence Sanitary District
. ..................................... —--------------------------------- ........
6/1/26
.......................
Signature of Hauler Date
............--............... ................................. ................. —-—---------_..._................_..
Signature of Receiving Facility(or attach facility receipt) Date
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