HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 225 CARLTON LANE 12/19/2025 lugCommonwealth of Massachusetts Town of Nor�h Andover
City/Town of_K
System Pumping Record DEC 2 9 2025
Form 4
DEP has Provided this form for use by local Boards of Health. tPelkrtbut the
information must be substantially the same as that provided here. Before using this form, check with y to
local Board of Health to determine the form they use. The System Pumping Record must e
the local Board of Health or other approving authority within 14 days from the Pumping date insubmitted
accordance with 310 CMR 15.351.
Facility—Information
----------------
Important:When
filling out forms I. System Location:
On the computer,
use only the tab L
key to move your Address
cursor-do not
use the return �ax A�� A'
key. CRY/town
Mate--
2. System Owner Zip Code
Name
Address(if different
State
Zip Code
—
oP�Up ping Record 0�rd �Tej�Wh—,D n�eN Number
1. Date Of Pumping
Date 2. Quantity Pumped:
3. Component: 0 Cesspool(s) Gallons
Septic Tank 0 Tight Tank n Grease Trap
E3 Other(describe):
4. Effluent Tee Filter Present? 0 Yes 0 No If Yes, was it cleaned? 0 Yes 0 No
5. Observed condition Of Component Pumped:
6. S tern Pump By:
Pump
N
( Vehicle
Company
7. Location where contents were disposed:
CA
Sign tu ' f Hauler
Date
Signature of Receiving Facility(or attach facility receipt)
t5fbrm4.doc-11/12
System Pumping Record.Page 1 of 1