HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 1010 JOHNSON STREET 9/12/2025 Commonwealth of Massachusetts Town of North Andover
City/Town of
System Pumping Record OCT 6 2025
Form 4
DEP has provided this form for use by local Boards of HealtH"t rif 3Mn",tbut the
rej '.
information must be substantially the same as that provided here. Befo u i g 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 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:
Pab
............. ............
Address(if different from location)
C !Town state Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component: r-1 Cesspool(s) Sep Tight Tank ❑ Grease Trap
El Other(describe): ...... - ---------
4. Effluent Tee Filter present��Ye) E:1 No If yes, was it cleaned , 11 Yes E] No
5. Observed condition of component pumped:
6. System Pumped By:
----- ------
Name Vehicle License Number
............
Company
7. Location wher contents were disposed:
7' .....--------------- ----------
Signature of HauleiY� _ Date
Signature of Receiving Facility(or attach facility receipt) Date
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