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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 162 ABBOTT STREET 3/10/2025 Town of North Andover <C\ Commonweal h of Massachusetts APR 2 3 2025 City/Town A.1 CIL"e-"'c System Pumping Record Health Department Form 4 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 CIVIR 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 A cursor-do not 4C15 use the return Al vrml-efl .............. ------- --------------- key. City/Town State Zip Code 2. §X§.tem Owner: Name Address(if different from location) ...............-------- .............. ................................. City/Town State Zip Code Telephone Number B. Pumping Record "3 cd/ / 1. Date of Pumping - -Z� ---. 6 ---------- Da �/ ------- 2. Quantity Pumped: te Gallons 3. Component: R cesspool(s) BSeptic Tank E] Tight Tank R Grease Trap r-1 Other(describe): 4. Effluent Tee Filter present? F-1 Yes Ej No If yes,was it cleaned? R Yes ❑ No 5. Observed condition of component pumped: ----—------------- 6. System Pumped By: ❑ 75"_' ...... --------------- ------ -------------------------- �54 Vehicle License Number Company 7. Location where contents were disposed: .......--------- ign re H..uier ----........ Date Signature ving Facili arlittach facility receipt) Date t5form4.doc-11/12 System Pumping Record-Page 1 of 1