HomeMy WebLinkAboutPumping Record - Septic Pumping Slip - 550 TURNPIKE STREET 12/9/2024 t\- Commonwealth of Massachusetts Town of North Andover
�Ujpp City/Town of _P10c4l j4jjcboeo DEC 10 2024
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 CIVIR 15.351.
A. Facility Information
Important-When
filling out forms 1. System Location:
on the computer,
use only the tab 4�-S-() M r r, P .
key to move your AdUress
cursor-do not
use the return NOIN-t A yX&1 jo
key- Cityllown State Zip Code
2. System Owner:
P'14-A TV\y!N\�
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component: 0 Cesspool(s) ❑ Septic Tank E] Tight Tankj Grease Trap
C] Other(describe):
4. Effluent Tee Filter present? E] Yes rA No If yes,was it cleaned? M Yes C] No
5. Observed condition of component pumped:
6. System Pumped By:
Name Vehicle License Number
ompany
7. Location where contents were disposed:
A
ture of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t6forrn4.doc-11112 System Pumping Record-Page 1 of 1