HomeMy WebLinkAbout- - Septic Pumping Slip - 1850 SALEM STREET 8/14/2026 Commonwealth of Massachusetts Town of tl-' Andover
...................
City/Town of NORTH ANDOVER 19 2026
.......... AUjSystem Pumping Record
Form 4
fj�n alth Department
s
DEP has provided this form for use by local Boards of Health. Other may be sed, 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 CIVIR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 1850 SALEM ST
--------------------- - ..........
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:
PAULHUDSON
Name
reaan
Address(if different from location)
.......—-------
City/Town State --
Zip Code
Telephone Number
B. Pumping Record
8/14/26 1500
1. Date of Pumping ate - 2. Quantity Pumped: Gallons
3. Component: M Cesspool(s) Z Septic Tank n Tight Tank n Grease Trap
❑ Other(describe): ................. -------------- ....... ...........
4. Effluent Tee Filter present? n Yes n No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
GOOD CONDITION
.. ...........----------- ........... ............--- ........................
6. System Pumped By:
JAY CURRIER H79406
N.. ----------------
ame Vehicle License Number
J'S SEPTIC & DRAIN
Company
7. Location where contents were disposed:
GLSD
8/14/26
----------------------------------- ..........- ............. ...............
Sign at f Date
Si a'hre'o'-f'R"e,--c--e-i-v--i-n--g--F--a--c-il--i-t-y-(or—atta-c---h facility receipt) Date
t5form4.doc-11/12 System Pumping Record-Page 1 of 1