HomeMy WebLinkAbout- - Septic Pumping Slip - 227 GRANVILLE LANE 8/3/2026 Commonwealth of Massachusetts Town of North Andover
City/Town of NORTH ANDOVER
System Pumping Record AUG 10 Z026
Form 4
DEP has provided this form for use by local Boards of Health. OthV@44lPqj)L§AN' Pqk
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 227 GRANVILLE RD...............---—---------- ........ ...........................
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
use the return 11 City/Town I I 11 I I I -- ................... State Z I-ip.Cade
- -
key,
2 System Owner:
JAKE CHACE
Name
soon
--------------------------------.............
-Address(if different from location)
------------------------------------------- ...........-——----CitylTown State Zip Code
........ -------------................ ..........
-telephone Number
B. Pumping Record
1. Date of Pumping bate 8/3/26 2. Quantity Pumped: -Lallans
. -1500 I
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank M Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? E Yes ❑ No If yes, was it cleaned? Yes ❑ No
5. Observed condition of component pumped:
GOOD CONDITION
..-- 11,11,1111-1.1 -..............
6. System Pumped By:
JAY CURRIER H79406
........- -----------------
Name- Vehicle License Number
J'S SEPTIC & DRAIN
Company
7. Location wh e ntents were osed:
GLSD
8/3/26
......... ... ---------
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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