HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 507 SALEM STREET 12/3/2025 Commonwealth of Massachusetts
N r City/Town of No.AndoverTown of North Andover
=
w System Pumping Record
w
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provid d tier .,'03 m, check with your
local Board of Health to determine the form they use. The System Mump g ecor 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 1. System Location
on the computer, y ,
use only the tab
key to move your Addresscursor--do not
use the return _ _-.... - -.— _
key.
City/Town State Zip Code
2. System Owner:
rah
Name _ --
nan
Address(if different farm location)
No.Andover MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping bate 2. Quantity Pumped: L'al lon s ...__.... .. .____._
3. Component: Cesspool(s) Septic Tank Tight Tank Grease Trap
Other(describe):
4. Effluent Tee Filter present? j Yes J No If yes, was It cleaned? No
5. Observed condition of component pumped:
6. Syste Pu° ped --
Z,
Na e Vehicle License Number
St arts Septic 58 So Kimball St , Bradford,MA
__.._.... ... _......._. _
Company
7. Location where contents were disposed:
20 So.Mill St.,Bradford,MA
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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