HomeMy WebLinkAboutSeptic Pumping Slip - 550 Turnpike St - 2025-02-17 - Septic Pumping Slip - 550 TURNPIKE STREET 2/17/2025 Town of North Andover
&\ Commonwealth of Massachusetts FEB 19 2025
City/Town of_AZ0r-WA-r)AWQr
System Pumping Record Health Department
Form 4
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
iiiiing out forms 1. System Location:
on the corriputer, I x
use ordy the tab C)
key to move your Address
cursor-do not
use the return Cityrrown 81QCbn-- nlnue.,�- MA
key. sate Zip Code
2. System Owner:
.........
Address Of different from location)
Myrrown state hp Code
B. Pumping Record
1. Date of Pumping pa 2. Quantity Pumped:
Y�- Gallons
3. Component: ❑ Cesspool(s) Tank ❑ Tight Tank t-A Grease Trap
F-1 Other(describe):
4. Effluent Tee Filter present? [] Yes No If yes,was it cleaned? C] Yes F1 No
6. Observed condition of component pumped:
S. System Pumped By:
Nam Vehicle License Number
7. Location where contents were disposed:
A o
_jWZ41
—1 a
'48"ture of Hauler Daft
Signature of RW*MM Facift(or attach fadity recelpQ Date
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