HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 30 VEST WAY 5/8/2025 I L\ Commonwealth of Massachusetts Town of North Andover
City/Town of '
System Pumping Record MAY 15 2025
Form 4
DEP has provided this form for use by local Boards of Health. Ot
information must be substantially the same as that provided here. using this"Orm., Agwith 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 —�XUL-Q.-.E—,�--*--- ----��-
key to move your Address
cursor-do not
use the return —.-Aft
.. .............
key. City/Town State Zip Code
VQ 2. System 0,weer:
w�' S\ -------------- —------
Name I
Address(if different fram location)
City/Tow ------ _. -- ___....---____ - J--- - � .,.�
n State Zip Code
---------------
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: r-1 Cesspool(s) peptic Tank Fj Tight Tank ❑ Grease Trap
M Other(describe): -
4. Effluent Tee Filter present? [aYes n No If yes,was it cleaned? 211Yes 0 No
5. Observed condd*�fi f o component pumped:
C.
-----------
6. System Pumped By:
me v Vehicle License Number
f
Company
7. Location w re contents were disposed:
—------------------
................................
Signa of Had Date
Signature eceiving Facility(or attach facility receipt) Date
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