HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 440 BOSTON STREET 4/3/2025 Commonwealth of Massachusetts Town ® North Andover
........... IV) Al
City/Town of r ev APR 23 2025
System Pumping Record
Form 4 Health De
DEP has provided this form for use by local Boards of Health, Other forms may be usePVt Went
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,
.- q-1,(q 1
I-I- � O-S
use only the tab .......------------ --------- ------
key to move your Add
ss
cursornot
use the return 7
key. City/Town State Zip Code
2. System Owner:
111
Name
............... .......... -----------
Address(if different from location)
------------------------ —State----- z ip"Cod,e
--
City/Town
Telephone Number
B. Pumping Record
1. Date of Pumping ----------------2. Quantity Pumped: -
Date Gallons
3. Component: ❑ Cesspool(s) Pl--Septic Tank M Tight Tank ❑ Grease Trap
R Other(describe): ... ................... ---------------
4. Effluent Tee Filter present? El Yes F-1 No If yes, was it cleaned? R Yes ❑ No
5. Observed condition of component pumped:
-----------------............ ------------------------------------- ............................ —---------------- ...........................................
6. System Pumped By:
ey -l- k'//(c C1
. f � _ 4� ---- ----- ---
me Vehicle License Number
--- _ _
Company -7-
7. Location where contents were disposed:
......................---------- ------- ------------------
---- ---------------- ............. ---------------------------------
Signat e au e Date
M.
........... .............................- .............................
Signature o III�a§-Vacility(or attach facility receipt) Date
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