HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 102 SUGARCANE LANE 4/17/2025 Commonwealt of Massachusetts Town f North Andover
City/Town of cf'4-' A c „ o�ex -
A R
2025
m System Pumping Record
Form Health park
en
DEP has provided this farm 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
the tab
on SystemLocation:
use only the computer, _ (, ..
y _-_ _ -.-.- — --------- .... .
key to move your Address
cursor-do not t
use the return _ ......_. - d� .__ _ ----. -------
key. City/Town state Zip Code
m 2, System Owner:
Name
r t
Address(if different from location)
.__ _ _ _. . _
- .. . -.---- ..
.............._........ m._._...._—_ _.....
C__..ity[Town state Zip Code
-- - .R..... "..__.. --------- _......
Telephone Number
B. Pumping Record
1. Date of Pumping gate - ............ 2. Quantity Pumped: Gail ons
_-.
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Crease Trap
❑ Other(describe):
4, Effluent Tee Filter present? Yes ❑ No If yes, was it cleaned? Wyes ❑ No
5. Observed condition of component pumped
_.._._._._ __::_IJ............__.-.... . _.
6. System Pumped By:
'Pa -
me Vehicle license Number
Company
7. Location where contents were disposed:
M
taule
: .-_ _.._.. ...... . _._.. ._ _.---- _.. - -- ......._.. .............
Signature Date _... - ......
atuivirgg...Faciltly(or attach facility receipt) Date
t5form4.doc•11f12 system Pumping Record•Page 1 of 1