HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 101 FOSTER STREET 7/29/2025 Commonwealth of Massachusetts
67� City/Town of TOWn
of Nofth Andover
System Pumping Record
Form 4
SEP 2025
DEP has provided this form for use by local Boards of Health. Other 0 ms may be used, but the
information must be substantially the same as that provided here. BA19afto D heck with your
local Board of Health to determine the form they use. The System Pumping Recor%wtdEftitted 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,
use only the tab
key to move your Address -------- .-.--------
cursor-do not
use the return
key. State -2ip'-do"-d-e,-
2- System Owner:
v,
dr-ess--(i.f.-di—ffe-r—ent—fr-o-m---- ------ ------
location)
-6—tyffc�
State Zip Codew—n
------------
Telephone Number
B. Pumping Record
1. Date of Pumping
Date 2. Quantity Pumped:
-Gallons
3. Component: 7 Cesspool(s) Septic Tank ❑ Tight Tank Fj Grease Trap
❑ Other(describe):
4. Effluent Tee Filter presen(TY:e�sh Nd' If yes, was it cleaned?(Des M No
5. Observed condition of component Pumped:
6. System Pumped By:
Name
Vehicle License Number
1504RC-
�Cam�pany
7. Location w ere contents were disposed:
—----------------- ........
6
Signature of Nat er Date
Signature of Receiving Facility(or attach facility receipt) Date —------
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