HomeMy WebLinkAboutSeptic Pumping Slilp - 11-27-2024 - Septic Pumping Slip - 11/27/2024 Commonwealth of Massachusetts
City/Town of L, -a TO
L Wn of North Andover
SYSteM Pumping Record
Form 4 JAN
12025
DEP has Provided thig'form for use by local Boards of Health. Other b used, but the
local Board of Health to determine the form they use. I
information must be substantially the same as that provided here, Be*64 A% ' u ck W'th your
I
r us
the local Board of Health or other approving authority within 14 days from the pu��rd"
'The System Pumping Re tDrd r us to
accordance with 310 CIVIR 15.351. mping date in
A. Facility lnioiim—�ation ___
---'-
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab
key to move your -Address
cursor-do not A
use the return "
key. City/Town
State
2. System Owner:
Apr,Cube
Name
Address(if
different-from
Zip Coda
B. Pumping Record
AW)C)
1. Date of Pumping - 2. Quantity Pumped: -dajj-
1 Component: bate (34j�------------1-1---
0 CessP001(s) Septic'Tank El Tight Tank 0 Grease Trap
El Other(describe):
4. Effluent Tee Filter present? El Yes E3 No If yes, was it cleaned? Yes No
& Observed condition of component Pumped:
6. System Pumped By:
Name
Vehicle License
Company
7. Locati?,A where contents were disposed-
S k
6-ni
tore of Date .......
WOMAdoc-11/12
System Pumping Record•Page 1 of 1