HomeMy WebLinkAboutSeptic Pumping Slip - 11/7/2024 - Septic Pumping Slip - 1 POND STREET 11/7/2024 Town of Nofth Andover
Commonwealth of Massachusetts
City/Town of d ,r, - FEB - 4 2025
} 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 t forms 1. System on the computer,
use only the tab _Location:
� � !" ° ".p
key to move your Address m _ . . ...._-. .........__
cursor-do not
_ ._ _
use the return _. ..
key. City/Town State Zip Code
2. System Owner
r
m Nam..
e
Address(if differentfrom location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping f _ - Gallons
2. Quantity Pumped: -
Date
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): _ _------- _ .......-------------------
4. Effluent Tee Filter present?o
Yes ❑ No If yes,was it cleaned? Yes ❑ No
5. Observed condition of component pumped.
6. System Pumped By:
/ Vehicle License Number
Name
µ . . - '�Company
7. Location wh , ntents were disposed:
_ - .. . ............................ ._ ........ ._._.. ---- .._ .---..._
Si atu of Hauler Date
Sign tore f R awing Facility(or attach cility receipt) Date
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