HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 500 REA STREET 10/16/2025 Town of NorthAndover
Commonwealth of Massachusetts OCT
-v- r City/Town of
System Pumping Record
Form 4 _�apailment
DEP has provided this form for use by local wards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using 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.
MOUSE: fron ack side rear ifi. riht
A. Facility Information BUILDING: -fro t back side rear left right
DECK: under
Important:When
filling out forms 1. System Loca ' n:
on the computer, /
use only the tab ......
key to move your Address `—
cursor-do not �~ MA
use the return City[Town
4r-ode
key.
2. Syreer:
r7
.�w Name
rrrrm ��V
Address(if different from location)
MA
City(Tawn State �Cade
Telephone Number
B. Pumping Record
J
1. Date of Pumping __— 2. Quantity Pumped:
p g Date ~_..._____. Gallons
3. Component: (❑ Cesspool(s) [:° e tic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): _._.__.___________.__._.___.____-_-_.-.___._.___._---------.__ ____-__._._______.___.---.__..-.._.
4. Effluent Tee Filter present? ❑ Yes a If yes, was it cleaned? M Yes ❑ No
5. Observed condition of fcomponent pumpej:
6. ystem Plumped By:
Dave Tin Mass 1AA95E Ma s 1AD31Z
Name __—._- — _ ---.__ Vehicle license Number
n Enterprises, Inc.
Company
7, ion h Ojspesed:
LSD
- - ___.
Signature of Hauler Date
Signature of Receiving Facility(ar attach facility receipt) Date
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