HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 165 CARLTON LANE 11/6/2025 Commonwealth of Massachusetts Town of Nofth Andover
City/Town of L,,,IL
1 System Pumping Record NOV 10 2025
Form 4
Heafth
DEP has provided this form for use by local Boards of Health. Other forms n9pAqw,99the
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 CIVIR 15.351.
A. Facility Information
Important:When
filling out forms I System Location:
on the computer,
use only the tab d ifLla
key to move your Address
cursor-do not
use the return Nc,--441
key. City/Town
State
2. System Owner: YIP C—od—e --�
A'044"S
Name
Address(if different from location)
Cki'-T�own -State Zip Co de
one N
B. Pumping Record Telephone
1. Date of Pumping 4
Date 2. Quantity Pumped:
Gallons
3. Component: Gallons
Cesspool(s) Septic Tank El Tight Tank n Grease Trap
C3 Other(describe):
4. Effluent Tee Filter present? El Yes Ej No If yes, was it cleaned? ❑ Yes El No
5. Observed condition Of component Pumped:
6. System Pumped By:
Name
0 Vehicle License Company
7. Location where contents were disposed:
Sign re"'f Hauler
Signature or Receiving Facility(or attachfacility receipt)
pate
t5form4.doc-11112
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