HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 7 INGALLS STREET 9/8/2025 Commonwealth of Massachusetts own of
City/Town of lVorth Andover
System Pumping Record SSA 2025
Form 4
DEP has provided this form for use by local Boards of Health. Othe p0e used, but the
information must be substantially the same as that provided here. Before ut Xi I Record
your
local Board of Health to determine the form they use. The System Pumping Record mus mitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15351.
HOUSE: front back (de rear Q011ght
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab
key to move your Addre Vs
cursor-do not MA
use the return
City own Zip Code
key.
2. System Owner:
Name
Address(if different from location)
MA
ItyrTown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Data 2. Quantity Pumped: _Gallons
3. Component: 7 Cesspool(s) peptic Tank 7 Tight Tank 7 Grease Trap
F-1 Other(describe):
4. Effluent Tee Filter present? 7 Yes No If yes, was it cleaned? ❑ Yes Ej No
5. Observed condition of component pumped:
6. Syste w,,umped By:
Dav__ ............... Mass 1AA95E 6�MiAD�31 Z'-1'__ ____Nam
N, Vehicle License Number
B at_t_—Iter rises, Inc.
Company
7. Vjo/ where contents were disposed:
_Signature of Hauler Date
Signature of Receiving 1Fajr_ity(or aktach facility receipt) Date
t5form4.doc-11/12 System Pumping Record-Page 1 of 1