HomeMy WebLinkAboutSeptic Pumping Slip Commonwealth of Massachusetts R.
City/Town of North Andover
System Pumping Record � '� 2 6 2024
Form 4
DEP has provided this form for use by local Boards of Health. Other fQrms'm y be�s, ed, but the
information must be substantially the same as that provided here. Before using tfii �forlxt;`i��tpk 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 Citylrown State Zip Code
key.
r�
2. System Owner:
North Andover Waste Systems
Name
nays
Address(if different from location)
City/Town State Zip Code
617-922-5724
Telephone Number
B. Pumping Record
1. Date of Pumping Dag 24 2. Quantity Pumped: 3500Gallons
3. Component: ❑ Cesspool(s) ® Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes,was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Fernando Costa
Name Vehicle License Number
Service Pumping&Drain Co., Inc.
Company
7. Location where contents were disposed:
GLSD
�V-a� C0zta-1 9.9.24
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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