HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 23 FOREST STREET 10/7/2025 Town of North Andover
` Commonwealth of Massachusetts
= , r City/Town of _ OCT 7 202
System Pumping Record
7 Form 4
. ., o,9lfh Depart r�
DEP has provided this form for use by local Boards of Health. other forms may be uses, bt��the
Information must be substantially the, sarne 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 __ _—__—_ -------
HOUSE: fran bac sid re'e3eft right
A. Facility Information BUILDIh7G: front �7a�ck side re i lcft rifijit
Important:When
DFCK: under
filling out forms 1. System Locatiom
on the computer, P
use only the tab
key to move your Ad ess
cursor-do not MA
uae the return
Key, City/Town State Zip Code
IdL �I 2. System Own r:
�J r
Nance
"'� Address (if different from locatirnn)
MA
City/Town State Lip Cady,
Teleohone Number
B. Pumping Record
1 Luke of Pumping . -_....._._____ 2 Quantity Pumped, 4� _..
Cate Gallons
3. Component: ❑ Cesspool(s) [" optic Tank ❑ Tight Tank ❑ Grease Trap
[� other (describe:): __ -_.._-_ _--- . ________._
4. Effluent Tee Filter present? Yes [_] No If yes, was it cleaned? ET-Yes [T fJa
5. Observed condition of com m
p onept� uped
�( �
5. (r�T,)
Pumped By:
2
ined Mass 1AA95E Mass 1AD31,
Vehicle License Nurn er
n Enterprises, Inc.
Cnrr�pa ny w.w..�
T Lo(jation where contents were distaosed:
Signature of Hauler Date
E>ignalure of Receiving Facility(or attach facility receipt) Date
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