HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 1070 SALEM STREET 6/16/2025 Commonwealth of Massachusetts 70,1111 If North Andover
City/Town of
Systet-n Pumping Record JUN 16 2025
Form 4
DEP has provided this form for use by local Boords of I-ca Health D
th. Other forms may be IPP,, Iqftnt
information must be substantially the same as, that provided here. Before using this form,, check will) 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 C M R 15.351.
HOUSE front back side ea(::,P-3 righz
A. Facility Information BUILDINGi front back side rear left fight
Important:When DECK: u n d 0 r
filing Out fO(rr)S 1. Systern Locatlorl:
on(he computer,
use only then tab to
key to move your Add ess
cursor -do not
use the feklfn MA
key. SlateCit Zip Code
2, SyNern iei:
Address (If different from location)
MA
CIty(Town State Zip Code
Telephone Nurnber
B. Pumping Record
ro
1, Date of Pumping 2. Quantity Pumped...
OaleGallons
I Component: ❑ Cesspool(s) Septic "rank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe),
4. Effluent Tee Filter present? 0 Y / El No If yes, was it cleaned? Yes [] No
5, Observed condition of C m ponen(�P"nlped.
----------— ----- ---------
6, Systern P4jmped By:
Dave Tln� Mass 1AA95L7 ass '1 AD3
-----------
Narne Vehicle License Numb
Company
7, ocaft n where contents were disposed:
Signature of Hauler Date
Signature of Receiving Facility (or a(lach facility feceipl) Date
16(orrn4.doc� 11/12 Systern Pumping Record p,g,