HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 20 FULLER MEADOW ROAD 10/16/2025 Commonwealth of Massachusetts Town Of North Andover
City/Town of
System Pumping Record OCT 16 2025
Form 4
DEP has provided this form for use by local Boards of Health. Othe�I(Pr Lt4ao"614r
information must be substantially the same as that provided here. Before using this form he?Twith 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.
o t back side re left""/4 ght
H0USE-.---(f�rr a( -
A. Facility Information BUILDING: Tr"ont back side rear left right
DECK: under
Important:When
filking out forms I, System Location:
on the computer, ('-Orw
use only the tab _j
key to move your Address
cursor-do not MA
use the return Zip Code
key, CityrTown
2, System Owner
----------
Name
Address(if different from location)
MA
State Zip Code
-Telephon>�Num b e r
B. Pumping Record
1, Date of Pumping Gallons
2, Quantity Pumped:
3, Component: Cesspool(s) Septic Tank El Tight Tank ❑ Grease Trap
❑ Other (describe): ...................
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? F� Yes [-I No
5. Observed condition of component pumped:
---------------
6. System Pumped By:
Dave Tl MasslAA95E Mass IAD314".,.
Name Vehicle License Number
Enterprises, Inc.
corrip-Miny
T Location where contents were disposed:
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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