HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 116 OGUNQUIT ROAD 2/20/2025 Commonwealth []fMassachl,isefts Town of North Andover
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Form 4
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DEP has provided this form for use by local Boards of Health, D�Mt�'�����������oused, but�w���»whe
information must be substantially the same as that provided here. Before using
' this form, check with your
local Board Df Health to determine the form they use The System Pumping Record must be submitted in
the local Board Of Health or other approving authority within 14 days from the pumping date in
accordance with 310CK0R 15.351 -
back side rear I rig
A. FaC'|^h/ |nf<3rmaf'{}M BUILDING: front beck side rear left right
Important:When DECK: under
filling out forms 1. System Location,
on the,computer,
use only the tab
key m move your Address `/ i/ -------
cursor'unno| MA )
use the ogum
key, City/Town m°m Zip Code
2� System Owner:
LID
=21111�1 Name
MA
Qty/Tnwn —
-f-ele—phone Nu
B. Pumping Record
3. Component: Cesspool(s) Septic Tank Tight Tank Grease Trap
[] Other (deaohbe)�
4, Effluent Tee Filter present? D Yea No If yee, was it cleaned? [] Yea 7 No
5� Observed condition uf component pumpeU
6. System Pgroped By,
Oeve T|ne
Name
ea�son Fnierprises, I
7, Location where contents were disposed.
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