HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 217 GRAY STREET 5/8/2025 IC TOM of North Andover
4�- Commonwealth of Massachusetts
City/Town of MAY 15 2025
System Pumping Record
Form 4 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 '�- )--1 only the tab --------------------------------------
..............I -------
key to move your A ress
cursor-do not e................... 1L
use the return +-
key. City/Town State Zip Code
2, Syriem Owner:
---—-----------
Name
Address(if difFerenk from location)
............ _-----
City/Town State Zip Code
..................
Telephone Number
B. Pumping Record
1. Date of Pumping Date- 2. Quantity Pumped: Gallons
. I.
3. Component: ❑ Cesspool(s) -Septic Tank M Tight Tank R Grease Trap
F-1 Other(describe): —---------- --------------------------- .................
4. Effluent Tee Filter present? 19"Y' es Ej No If yes,was it cleaned? Yes Fj No
5. Observed condition of component pumped:
C
6. System Pumped By:
'. 'I W ' 7 -7 6
................. ---------- ----------- ------
Ze Vehicle Lic nse Number
am
ompa
ny
7. Location where contents were disposed:
....t....... - -------................ .. . ......
Signature '
--------------.......................... ----------------------------
Date
............................... ................... ...........--------
Signature of Receiving Facility(or attach facility receipt) Date
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