HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1420 GREAT POND ROAD 11/20/2024 'r-
1"'\ Commonwealth of Massachusetts I own of North Andover
. .. ..... City/Town of —/Jz-1 MAY 5 2025
System Pumping Record
Form 4
Health Departme t
DEP has provided this form for use by local Boards of Health. Other forms may be used, but t9e
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, / a,61-
qzo
useonly the tab ----------- .......... ......------------- .............. ............
key to move your Address
cursor-do not
use the return
.
-
key. itv/ToW? State p Code
2. System Owner:
VQ J,CA ot>
Name
---------------- -------------------------------
Address(if different from location)
Ciiy/f
n State Zip Code
Telephone Plumber
--"
B. Pumping Record �
I. Date of Pumping Y- 2. Quantity Pumped: Uoo
Date Gallons
3. Component: El Cesspool(s) VAeptic Tank F1 Tight Tank F-1 Grease Trap
M Other(describe): I 1-11.1--l- ------ - - -------- ........... ................ .................--
4. Effluent Tee Filter present? R YesE] No If yes, was it cleaned? M Yes n No
5. Observed condition of component pumped:
------6 '-
uo
6. System Pumped By: 7 0
Vehicle License Number
..... ------
�ame .....----------
I
Company
7. Location where contents were disposed:
---------- ------
.............. ................... --------------
- --
Signatur a u I a r Date
------------
iIg natur" of R- v' a it 0'-1"r'attach facility receipt) Date
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