HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 615 BOXFORD STREET 4/3/2025 Town
Commonwealth of Massachusetts I own of North Andover
City/Town of Ncr c�o,'e
2 3
.... . ........ System Pumping Record APR 2025
Form 4
Health pp
DEP has provided this form for use by local Boards of Health. Other forms may e
u eyqMot
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, Pei-
use only the tab
key to move your Aqdd�ess
cursor-do not S7
use the return ---------------
key. City/Town State Zip Code
2. System Owner:
'A -----------
ame
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping RecordZ,�-T
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank M Grease Trap
F1 Other(describe): .............
4. Effluent Tee Filter present? [0"Y'esE] No If yes, was it cleaned? n Yes Fj No
5. Observed co ition of component pumped:
.............
6. System Pumped By:
me
Vehicle License Number
mcfil A L4 I n,4,J
Company
7. Location where 9entents were disposed:
............—---------............................. .......... -----------
7-
Sign re auler Date
a —-------------- ..........................
Signature of R iv in n o r a 9,kelity(or attach facility receipt) Date
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