HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 100 TUCKER FARM ROAD 2/24/2025 'Own of North Andover
Commonwealth of Massachusetts
9A City/Town of
MAY 5 2025
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 /-,-e r
key to move your Address
Cursor-do not
use the return
key. City/Town state Zip Code
VQ 2. System Owner: I
K K
Address(if different from location)
Gity/Town State Zip Code
—----------
Telephone Number
' 13. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: E] Cesspool(s) Septic�Tan n Tight Tank R Grease Trap
El Other(describe):
4. Effluent Tee Filter present? n ts X No If yes, was it cleaned? E] Yes ❑ No
5. Observed condition of componen�pumped
6. System Pumped By:
-----------
Name Vehicle License Number
Company
7. Location wherp conte is were disposed:
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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