HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 210 HOLT ROAD 9/4/2026 Town of Notl Andover
Commonwealth of Massachusetts SEP 9 Z026
City/Townof North Andover
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,
210 Holt Road
use only the tab
___-._____.._..._.__.____-_._._...__._....._----..-_.-
key to move your Address
cursor-do not North Andover MA 01845
use the return ............. .............
key. City/Town State Zip Code
4:1 2. System Owner:
North Andover Waste Systems
... ................ ............. ------
ame
................. ------
Address(if different from location)
-6iiy-/T6wn--- State Zip Code
617-922-5724
Telephone Number
- ------—----------------
B. Pumping Record
1. Date of Pumping 9/4/26 2. Quantity Pumped: 3000
Date Gallons
3. Component: F Cesspool(s) RM Septic Tank R Tight Tank R Grease Trap
R Other(describe): (2)tanks
4. Effluent Tee Filter present? R Yes R No If yes, was it cleaned? R Yes E] No
5. Observed condition of component pumped:
good
6. System Pumped By:
Luiz Gomes 5733A
Name Vehicle License Number
Service Pumping&DRain
Company
7. Location where contents were disposed:
Greater Lawrence Sanitary District
...............
9/4126
Signature of Ha Date
................... . ................_..__.._...................___.__--
signature
of Receiving Facility(or attach facility receipt) Date
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