HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1806 SALEM STREET 8/28/2026 Commonwealth of Massachusetts Town of NOdh over
City/Town of NORTH ANDOVER
System Pumping Record SEP 2026
Form 4
Heallh Dep
DEP has provided this form for use by local Boards of Health. Other forms may be use WWWnt
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 -------------------------------------------
1806 SALEM ST .......
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
use the return -------------------
key. Cityrrown State Zip Code
VQ 2. System Owner:
ILIR KAVAJA
Name
renrn
Address(if different from location)
-C-ityamw n "State---- Zip Code
-Telephone-Number
B. Pumping Record
8/28/26 1875
1. Date of Pumping ... ........................... 2. Quantity Pumped: -Gallons- -----------
Date
1 Component: F-1 Cesspool(s) Z Septic Tank n Tight Tank El Grease Trap
n Other(describe):
4. Effluent Tee Filter present? Z Yes [I No If yes, was it cleaned? Z Yes n 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 where contents were dispo
GLSD
8/28/26
-
------------- —----------
Signature-of`- uler Date
,i 4�
........... .................. -------
Signature of Re ivi (o acMacility receipt) Date
yx
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