HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 28 FULLER MEADOW ROAD 4/30/2025 Commonwealth of M Ss?chpefts Tcwn of North Andover
City/Town of T C e)T MAY 5 2025
System Pumping Record
. ................ Form 4 i4caith Depart �Pt
DEP has provided this form for use by local Boards of Health. Other forms may be used, butM
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, W
4�use only the tab 41 2 d .........
key to move your Add a s
cursor-do not
use the return
key, City/Town State Zip Code
2. System Owner:
......... -----------------------------------
Name
Address(if-d-iff-e-rent'-f-ro-, ------- --m - ------------------
-6-ty-/Tow-n State -Zip-"-Code
--
Telephone Number
B. Pumping Record
1. Date of Pumping Quantity Pumped: -------------------------
Date Gallons
3. Component: D Cesspool(s) 2�Sept`ic Tank ❑ Tight Tank El Grease Trap
❑ Other(describe): ..........
4. Effluent Tee Filter present? F] Yes No If yes, was it cleaned? ❑ Yes F-1 No
5. Observed condT'Mon of component pumped:
--------------- .....-------------------------------
6. System Pumped By:
rc/ ro
Name Vehicle License Number
7 Company
-- y- -(�
pany
T. Location wher ntents were disposed:
..............---- ----------- ---------------
—77-77
Signor f Date
Signature a Facility ttach
d facility receipt) Date
ay
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