HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 770 FOREST STREET 11/7/2025 0W11 of North
Andover
s Commonwealth of Massachusetts
LLr City/Town of NOV202
System Pumping Renard
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 provided here. Before using this form, check with your
local Board of I-ieaith 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 315 CMR 15,351,
HOUSE front y-.ack side rear lef ripI t
A. Facility Information BUILDING: front back side rear left right
mportant: When DECK: tjnder
filling out forrns 1 System t_oCat10
on the cornpuler, �/7 �✓��
use only the tab
key to rnovr:your Ad rr s
cursor-do riot MA use the return _,.___. ._.-- ..__ __.___.. --._..__ ___.__.____..._ _ ____.._______._ __._.__.____ _ �...._-._._._ -.-----_ _.
trey. Cityffown _ ... State Zip Code
2. " stem Owner:
- -___- ' _ _ _ _ .
r��-,rr7r
Address (if different from) location)
MA
C;Ityrl own Staf _. ip Code
_ - _ _
Telephone Number
B. Pumping Record
1 Date of Pumping 2. uantit Pumped,
� p g Date y p Gallons
3. Component: Cesspools) [ eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): _. _..... __. ___ ...___--
4. Effluent Tee Filter present? C_] Yes Io If yes, was it cleaned? Yes ❑ No
5 Observed condition of component umhed:
07
5. S (k nt Pumped By: _...
ave TIneX _..._.--....... ._ Mass lAA95E Mass 1AD31Z
ame Vehdcle l.icensry NurribPr
ateson F�nter rises...Inc, .
Company
7 l.o tion where c t Itsrw ,
disposed,
LSD \
_____..__
Signature of Hauler Date
Signature of Fsecciving t-acility(or attach facility receipt) Date
t5form4.doc• 11112 System Burn{'ping Record Paw" 1 of 1