HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 30 INNIS STREET 6/23/2025 T^
Commonwealth of Massachusetts Tows of North Andover
lugCity/Town of JUN 2 3 2025
System Pumping Record
Form 4 Health 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 subrnitted 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, /'7
use only the tab
key to move your Address
cursor-do not
use the return ---LILL CA i kil?,
key. Cityfrown V1
2. System Owner:
Name
Cikyfrown
State
Zip e
a. Pumping Record --------------------
1. Date of Pumping
2. Quantity Pumped:
Gallons
3. Component: n Cesspool(s) Septic Tank F1 Tight Tank El Grease Trap
El Other(describe):
4. Effluent Tee Filter present? n Yes n No If yes, was it cleaned? 0 Yes n No
5. Observed condition of componert Pumped:
6. System Pumped By:
'1)( -
—LAI� 15
Name
Vehicle License Number
-Company
T L tion where contents were disposed,
Sinof Hauter
Date
Signature of Receiving Facility(or attach facility receipt) pate
t5foffn4.doc-11/12
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