HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 97 BRADFORD STREET 5/15/2025 commonwealth of Massachusetts C j
City/Town of,,,, Town of North Andover
V,t
System Pumping Record
Form 4 JUN 3 0 2025
DEP has provided this form for use by local Boards of Health. o for b d
information must be substantially the same as that provided hnrl"41,14 44kewith 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 informat-ion
Important:When
filling out forms I System Location:
u
on the computer,se only the tab
key to move your Address ......
cursor-do not
use the return
key, City/Town
State Zip Code
2, System Owner:
-Ei am
Address(if different from�iocaUon)
�/Town State Zip Code
B. PUMping-Record Telephone q�—mber—
I. Date of PumpingDate 2. Quantity Pumped:
Gallons
3, Component: 7 CeSSPOOI(S) Septic Tank E: Tight Tank 7 Grease Trap
Other(describe):
4, Effluent Tee Filter present? ❑ Yes No If Yes, was it cleaned? Yes No
5. Observed condition of component pumped:
P(X ,f
�6 tO
6. System Pumped By:
0/3?
Name Vehicle License Number
Wayne's Drains, Inc.
(50—rnpa—rly-
7, Location where contents were disposed:
"Signature offHaulpr
Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc-11112 System Pumping Record - Page I of 1