HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 1337 SALEM STREET 10/22/2025 Commonwealth of Massachusetts
Town of North Andover
h City/Town of
System Pumping Record
- 8 2025
DEC
Form 4
DP has provided this form for use by local Boards of Health.R qr f,;219pr�*MefAut the
a this
information must be substantially the same as that provided here. si g 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.
A. Facility information
Important:When
filling out forms 1, System Locqtion:
on the computer,
use only the tab 'S
key to move your Address
cursor-do not
use the return
CitylTown
key. State Tip Code
2. System Owner:
Address(if different from location)
State Zip Code
Telephone—Number
B. Pumping Record
1. Date of Pumping Date Ij 2. Quantity Pumped: 00
-'daflon—s
. 3. Component: n Cesspool(s(�&Se��ic Tight Tank Grease Trap
Other(describe): .
4. Effluent Tee Filter present? n Yes n NO' If yes, was it cleaned? El Yes Q No
5. Observed condition,of component pumped:
6, System Pumped By:
Name —Ve—hicle License Number -N--umber
-7
Company
7. Location where ntents were disposed:
Signature of Heater
Signature of Receiving Facility(or attach facility receipt) Date -------
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