HomeMy WebLinkAboutSeptic Pumping Slip - 4-18-2024 - Septic Pumping Slip - 32 OLYMPIC LANE 4/18/2024 Commonwealth of Massachusetts own of North Andover
City/Town of
FEB System Pumpin Record 2025
Form 4
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DEP has provided this form for use by local Boards of Health. Other forms may
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 t _key to move your Address
cursor-do not _ , ^
use the return .__ _. _.. _—._ _-- ...
key. CitylTown state Zip Code
2. System Owner:
rf ._,... ... _ ._ _ ...
Name
Address(if different from location)
City/Town state Zip Code
Teleph 11 one 11 N 11 u 11 mber
B. Pumping Record
1, Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ tither(describe):
4. Effluent Tee Filter present? Yes ❑ No If yes, was it cleaned? Yes ❑ No
5. Observed condition of component pumped:
6. Sstem Pumped By:
Name Vehicle License Number
Company
7. Location where contents were disposed:
a'
- -
signature of uler Date
signature of xtrng Facility(or attach facility receipt) Date
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