HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 352 FOSTER STREET 12/5/2024 Commonwealth of Mas lusetts Town Of North Andover
City/Town of q1117" , V
System Pumping Record MAY
5 2025
Form 4
DEP has provided this form for use by local Boards of Health. OW04h e
information must be substantially the same as that provided here. Before using Okfk,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 11 � —Z-- ............ ............ ......... .....................
key to move your A�d dress
cursor-do not &
-- ---------I.............'4j
use the return
key. ity own State Zip Code
VQ 2. System Owner:
.. ................
Name
Address(if different from location)
................ ........................ ...............
State Zip Code
— 2Wr-
3
Telephone Nu
B. Pumping Record
1. Date of Pumping - 2. Quantity Pumped:
DateGallons
3. Component: El Cesspool(s) Septic Tank F-1 Tight Tank R Grease Trap
❑ Other(describe): --— - ----------------------
4. Effluent Tee Filter present? F1 Yes F-1 No If yes, was it cleaned? Fj Yes R No
5. Observed condition of component pumped:
t"� - ---- .............. .................... --------------
6. S m Pumped By�
---------------
Name Vehicle License Number
d
Company
r 'P 01
7. Location wh contents were disposed:
............
Sign f er Date
............
Signatur eceivingEaci— (or attach facility receipt) Date
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