HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 995 FOREST STREET 9/2/2025 Commonwealth of Massachusetts
City/Town of Town of North Andover
System Pumping Record
Form 4 SEP 18 2025
DEP has Provided this form for use by local Boards of Health. 0 r forms ay be used, but the
information Must be substantially the same as that provided hen= -A#
local Board of Health to determine the form they use. The System PumpinW1l9-g Record must*jDI1rft6 ck with your
e
the local Board of Health or other approving authority within 14 days from the Pumping date insubmitted to
accordance with 310 CIVIR 15.351.
A. Facility Information
Important When
filling out forms 1. System Location:
on the computer,
use only the tab .L'a t e
key to move your Add ss
cursor-do not
use the return
St Zip Cod-�
key. Utyl I UW"
2. System Owner
Name
l�dress(if different from location)
State
Pumping Yip—do—de---
Ripcord ��.�Ta�lephoPumpingReco
1. Date Of Pumping
Uate 2. Quantity Pumped:
3. Component: G
0 Cesspool(s) Septic Tank 0 Tight Tank 0 Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? 0 Yes El No If yes, was it cleaned? ❑ Yes F-1 No
5. Observed condition Of component Pumped:
6- System Pumped By:
Name
1)�-('d vehicle Ucense Number
Co ~pony
7. Location where contents were disposed:
Sign of Hauler
01y"alule OT KeCelving Facility(or—attach facility—rece Date
t5fbfm4.d0C*11/12
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