HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1050 FOREST STREET 6/1/2026 Town of Wh Andover
IN" Commonwealth of Massachusetts
...........
City/Town of NORTH ANDOVER JUN 2 3 2026
mm System Pumping Record
Form 4 Health Department
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
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 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 1050 FOREST ST
............................... ...................................... ........................................................
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
usethe return ------------------_-_------------------------------- ....................
key. City/Town State Zip Code
11vo 011� 2. System Owner:
NANCY KRAVITZ
Name-----
reran
—-—------------------------ .......... ...............................................
Address(if different from location)
..............'_------ ............. ...........
—
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 6/1/26 2. Quantity Pumped: 1500 -------
DateGallons
3. Component: F] Cesspool(s) Z Septic Tank F-1 Tight Tank M Grease Trap
F-1 Other(describe): ............... ---—------------ ____............................................................
4. Effluent Tee Filter present? El Yes n No If yes, was it cleaned? ❑ Yes n No
5. Observed condition of component pumped:
-GOOD CONDITION ............. .......... ......... ............... .............
6. System Pumped By:
JAY CURRIER H79406
............
Name Vehicle License Number
J'S SEPTIC & DRAIN
_d6mp`an'y"_'_"-_
7. Location whe7xpntents were disposed:
GLSD
..........
6.1.26
------------------- -—-----------............... .........---------
�ig-na',e-of-Hauler- I e r Date
'. --—----------------------- .......................... -----------I................................ ... 1-1- 1—— ___ ------------- ----------
Signature of Receiving Facility(or attach facility receipt) Date
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