HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 55 VEST WAY 4/3/2025 Commonweal h of Massachusetts Town of Nor�h Andover
City/Town of �X+V� APR 2 3 2025
System Pumping Record
Form 4 Health 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 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab
key to move your Address
cursor
use the returnt
-./V -1-,f $WAX
key. City/Town State Zip Code
VQ 2. Sy ern Owner:
P'My VU C-r--1-1 aiz-'A/�
Name
ern
Address(if different from location)
..........
City/Town State Zip Code
Telephone Number'
B. Pumping Record
1. Date of Pumping bate, , 2. Quantity Pumped: dallons
3. Component: n Cesspool(s) epfic Tank ❑ Tight Tank F Grease Trap
ROther(describe): ................................... ...........---- --.................
4. Effluent Tee Filter present? F-1 Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
............ 1(--------------------- ------ --------------- ------------------------------................
6. System Pumped By:
kame - ------------------ ---------- -------
Vehicle License Number
Company
7. Location where contents were disposed:
--- -------------------- .......... -------
Signature auler Date
Signature eiving Facility(or attach facility receipt) Date
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