HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 115 CRICKET LANE 5/7/2025 -�&- -- City/Town of Commonwealth of Massachusetts
p Town of North Andover
System Pumping Record
M Form 4 JUL 10 2025
DEP has provided this form for use by local Boards of Health. OtheMmebbe used, but the
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information must be substantially the same as that provided here. I 11"pft with your
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local Board of Health to determine the form they use. The System Pumping Record must e SO mitted 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 only the tab
—------------
key to move your Address
cursor-do not
use the return —----- ---------------
key. City/Town State Zip Code
2. System Owner:
rob
----------- ...........------
Name
Address(if different from location)
C"wn-- -State Zip Cade
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) �2"'Septic Tank M Tight Tank ❑ Grease Trap
❑ Other(describe): ----------------
4. Effluent Tee Filter present? P Y No If yes, was it cleaned? ❑ Yes M No
5. Observed GOncItion of component pumped:
............. ...............
6. System Pumped By:
Name Vehicle License Number
Company
7. Location where contents were disposed:
------——-------
----------- --------------
Signature of Ha er Date
Signature —Receiving—Facility(or-attach facility receipt) —Date—
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