HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 79 FULLER ROAD 6/3/2025 Commonwealth of Massachusetts down of North Andover
'� - � City/Town of JUL 10 2025
System Pumping Record
Form 4 Health a
epartMent
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 submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CIVIR 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
key. City/Town State Zip Code
2. System Owner:
----------
Address(if different from location)
-6 7ify-r—row—n —- -----
ate Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank Tight Tank ❑ Grease Trap
El Other(describe):
4. Effluent Tee Filter present? M ycl�No If yes, was it cleaned? ❑ Yes M No
5. Observed condition of component pumped:
e,j-
6. System Pumped By:
Name -Vehicle License Number
130 C 7 Ar
Company
7. Location wh 7 re contents were disposed:
Signature of Ha er Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc- 11/12 System Pumping Record-Page 1 of 1