HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 96 LOST POND LANE 4/4/2025 Commonwealth of Massachusetts Town of North Andover
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_ 3 City/Town of
- MAY 5 2025
System Pumping Record
;ywHForm 4
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", 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 1 6 10
key to move your Address
cursor-do not
use the return ......._------ Ve
key. City/Town State Zip Code
2. System Owner:
Address(if different from location)
City/Town State Zip Code
9 7
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Telephone Number
' 13. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component: R Cesspool(s) (T��c DTa k F] Tight Tank E] Grease Trap
El Other(describe):
4. Effluent Tee Filter present? ❑ s No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
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6. System Pumped By:
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Name Vehicle License Number
_oofa C z e
Company
7. Location where,contents were disposed:
V61 A
Signature of Hauler Date
Signature of Facility(or attach facility receipt) Date
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f Receiving
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