HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1459 TURNPIKE STREET 8/18/2026 Commonwealth of Massachusetts Town of North Andover
City/Town of NORTH ANDOVER SEP 8 2026
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 CIVIR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 1459 TURNPIKE ST
---------------- ..................................... ..............-------------------- ..............--------------------
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
usethe return - --- - I�. . .................... ------------ ---------------- ------------ ..........
key. City/Town State Zip Code
VQ 2. System Owner:
AYAN CHOUDHURY
................. ............... --------------------—------------------- -----------
Name
reaan
..
A 6-6-r'e--s-s-(-i f d--i ff--e r e--nt—fr o-m-- ... ..1-o-c location)
i-on ..... ...................................
......................- .........................--------------------------------- ----.......----..............
City/Town State Zip Code
Telephone-- Number
B. Pumping Record
8/18/26 1200
1. Date of Pumping Date- 2. Quantity Pumped: -Gallons
... .-
3. Component: F-1 Cesspool(s) Septic Tank M Tight Tank ❑ Grease Trap
F] Other(describe): - - ---------- ................
4. Effluent Tee Filter present? r-1 Yes 0 No If yes, was it cleaned? M 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 disposed:
LSD
........................
8/18/26
.......... ....................
Si ure of Hauler Date
Signature of Receiving-Facility('o--r,--a,-ft—a--c-h-f-ac-ilit-y--receipt) Date
t5form4.doc-11/12 System Pumping Record-Page 1 of 1