HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 40 DUNCAN DRIVE 7/14/2025 __ Commonwealth of Massachusetts Town of Noofth Andover
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System Pumping Record JUL 149075
Form 4
DEP has provided this form for use by |oom| Boards ofHealth. Other foHe aw�
information must be substantially the same as that provided here. Before using thiofohn. cheoMi t your
local Board of Health tu 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 31OCyNR15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab
beym move your xddmee
cursor do not North Andover Massachusetts 01845
use the return
City/Town State �pC�e
_'�
2. System Owner:
wame
-------- Addman(if different from location)
Cdy�own S�te Z|pCoUn
(017) 312-1279
T*|*phuneNvmbwr
B. Pumping Record
00/18/25 2000
1 Qeta of 2 Quantity Pumped:� Date � � Gallons
3. Component: Cesspool(s) Septic Tank U Tight Tank Grease Trap
0 Other(describe):
4. Effluent Tee Filter present? El Yes D No If yes, was it cleaned? Yes No
5. Observed condition of component pumped:
good
8. System Pumped By:
Vandedoi Da|Dor 1AH23P
Name Vehicle License Number
Company
7. Location where contents were disposed:
Greater Lawrence Sanitary District
O0/18/25
Signature ovHauler - Date
Signature of Receiving Facility(or attach facility receipt) Date
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