HomeMy WebLinkAbout- - Septic Pumping Slip - 1601 SALEM STREET 8/11/2026 'L\ Commonwealth of Massachusetts pwn of Nc,
City/Town of NORTH ANDOVER
2026
System Pumping Record
Form 4
�...... ent
DEP has provided this form for use by local Boards of Health. Otherggi; h% e' ds�-8,'b'ut 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 1601 SALEM.§T_
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
,use the return .......------- -1------------— .............
key. Cityfrown State Zip Code
1 System Owner:
MATHEW MERRILL
............. -----------
Name
.................... .........--- ---- ........... ------- -_-_-----__-_..................
Address(if different from location)
I..................................
—
City/Town State Zip Code
Telephone-- 'Nu-mbier
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component: F1 Cesspool(s) Z Septic Tank F Tight Tank F-1 Grease Trap
ElOther(describe): ---- ................................... __-------------____..........................----------------------_-__............... .......
4. Effluent Tee Filter present? F-1 Yes [:1 No If yes, was it cleaned? E] Yes F] No
5. Observed condition of component pumped:
GOOD CONDITION
-_-------- ..............11...
6. System Pumped By:
JAY CURRIER H79406
-Name Vehicle LicenseNumber
J'S SEPTIC & DRAIN
...........
Company
7. Location where eats were disposed:
GLSD
.... ❑............. ........... -—-----------__---__ .................................. ..........................
8/11/26
Signature Hauler Date
-------
Signature of Receiving Facility(or attach facility receipt) Date
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