HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 45 BRIDGES LANE 4/9/2025 Commonwealth of Massachusetts
Town of North Andover
�- City/Town of
System Pumping Record MAY 5 202
Form 4
DEP has provided this form for use by local Boards of Health. tFieer� 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 CMR 15.351.
A. Facility Information
Important:when
filling out forms 1. System Location:
on the computer,
use only the tab _.._.__. __._..... ......_.._.__---------�� ? .✓_ a. . :Sy Yl.__ __._ ._._....__ _.. _._.......-.__.-----._. .. __.
key to move your Address
cursor-do not
use the return
key. City/Town State Zip Code
2. System Owner:
. --._.
_--
Name --------------._...____.._......__._..._...__......._._.-..__._..._.........__._..._..._.__._
..._- __.._. _._.._ . --..._. _,_ ._.....,_,... _.. _. . ___.._--- _............_..
Address(if different from location)
City/Town State r Zip Code
.........
Telephone Number
B. Pumping
1. Date of Pumping 2. Quantity Pumped: '`
Date Gallons
3. Component: ❑ Cesspool Septic Tank Q Tight Tank ❑ Grease Trap
❑ Other(describe): ......-.._._.._.._._._.---_ _..___...__..__...___....____:.........................___..__.__---._.—.�__.__._---..__._._.._._..._._..__..
4. Effluent Tee Filter present? ❑ Yes ❑ No- If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition,of component pumped:
m
_._... - - _.._.. .....------.._......._...._....
6. System Pumped By:
___._..._...........__.._`_ _._._... _ _.-....._ _____._.... -__ ___.. _.._.__._... .... _..-_----- ..-
Name Vehicle License Number
r. .3 ....._.._2
Company
. Location wherg contents were disposed:
6r
Calf e
Signature of Ha er _. Date
_..__.._._____._._ _.._._.__..___.....___-..-- ..._....___.....-__.__._.....w..___...... - ........_....___._.._____...
Signature of Receiving Facility(or attach facility receipt) Date
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