HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 414 FOSTER STREET 2/11/2025 Commonwealth of.Massachusetts Town of North Andover
City/Town of
yetem Pumping Record FEB 2 5 Z025
Form 4
DEP has provided thitform for use by local Boards of Health. tither fHea l th m Department
ut the
iftnInation must be substantially the 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 CAR 15.351.
A. Facility Infcrirrrliatlon
Oft out forms 1. System Location:
Or,the der,
use only the tab
key to move your Address
cursor-do not
use the return
key. City/Town __..._ ..
VQ 2. System Owner: ilp-Code
ararrrau
(lf dlPferent fir "locationi
cRyrrown
state zip code
Telephone Nu m b er _..__...._._
Is. Pumping Record
1. Date of Pumping Date 2. Quantity pumped;
3. Component.. 0 Cess (s) Septic Tank Tight Tank [� Grease Trap
0 Other(describe):
4. Effluent Tee Filter present's Q Yes No If yes, was it cleaned?
Yes El No
5• Observed=ndifion of component pumped;
S. Sys m pumped By:
Namenvl
Vehicle License Number
ny
7• Location where contents were disposed:
W
of He,wr
Sion
Date
Sttynature of ivinp f"ac. ty(ar facility rewipt)
WOMACIOC&11/12
Systam Funning Record*Page 1 of 1