HomeMy WebLinkAbout- - Septic Pumping Slip - 1423 SALEM STREET 7/31/2026 Commonwealth of Massachusetts down of North Andover
x City/Town of NORTH ANDOVER
System Pumping Record
Form 4
_ - DEP has provided this form for use by local Boards of Health. Other drvA4 QpaO"information must be substantially the same as that provided here. Before using this farm, 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, 1423 SALEM ST
use only the tab
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
use the return _. .._.....-- _- ---_..._._ __-_ -
key. CitylTown State Zip Code
2. System Owner:
ISABELLA INGRAM
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
7/31/26 1500
1. Date of Pumping _ _ 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) ® Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): __ - -
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ 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 wheW,do tents were disposed:
GLSD
,jr�'111-1�'
7/31/26
Sig 11 nature of Hau 11 l 11 er Date
_- ........._..
Signature of Receiving Facility(or attach facility receipt) Date
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