HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1365 SALEM STREET 7/24/2026 Commonwealth of Massachusetts Town WOW
City/Town of NORTH ANDOVER
4 AUGZ026
. .. ......... System Pumping Record
Form 4
Qepa,,menl
DEP has provided this form for use by local Boards of Health. OAV4 maybe 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,
use only the tab 1365 SALEM ST
------------------ .............. --------- ---------------------------—--------.11-----------
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
use the return ................ .................... ............. .................
key. City/Town State Zip Code
VQ 2. System Owner:
HELEN CUNNIFF____
Name
retran
-Address-(if---different-from- location) - -------
cit w--n,,- State Zip Code
Telephone Number
B. Pumping Record
7/24/26 2500
1. Date of Pumping bake------ 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Z Septic Tank R Tight Tank ❑ Grease Trap
PUMPED FOR REPAIRS - HALL PUMP
El Other(describe): --------------
4. Effluent Tee Filter present? R Yes E] No If yes, was it cleaned? E] Yes ❑ No
5. Observed condition of component pumped:
GOOD CONDITION
---—-------------------
6. System Pumped By:
JAY CURRIER H79406
Name Vehicle LicenseNumber
J'S SEPTIC & DRAIN
Company
7. Location where contents were disposed:
P GSP
L ----------- —------
lo
7/24/26
..........
Sign re o auler Date
i'cl u�r
gnature of Receiving Facility(or attach facility receipt) Date
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