HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 353 PLEASANT STREET 1/5/2026 Comi��onwealth of MassachLisetts Town Of Noqh Andover
c , r(a City/Town of
System Pumping Record Jq
y r% Form 4 � �
DEP has provided this form for use by local Board-. of Health. Other@ �> i but the
information must be substantially the same as that provided here, Before, using hi ntk will) your
local Board of Health to determine the form they use The System Pumping Record must be submitted ro
the local Board of Health or other apt,aroving @uthority within 14 days frorn the pt.,rnping date in
accordance with 310 CMR 1,15.351
S _. ft if?trt f-IC7L).,f;: front back re,ar
A. Facility Information BUILDING: front bark side rear left ripIrt
Important: When DEC<: under
flllitlg nut forms '1. System Location, ,
on the corntkutW, d ,e ) —
use only the tat, _ . - .� ) ..-_3 =_ _.P.,. .... .__.._.. _._. ...._.. .— ___..__—
ke;y to r OVe ycr,ur /\ddross � � � ------
cursor-do nol
use the: return Ctyrown State
f e_ _..__....
key
_. ._
Zip C:otie
(�f 2. Syste owner:
_.. ;�--_
AtlrSress (if different Irrarr7 location)
M/�
State
Zip Code
Telophonc P4r.irrrber
B. Pumping Record
1. Date of Pumping <> Chu )ntity Purrlped. ca
tions
3. Component; [] Cesspooi(s) [,� Septic -rank ( ] Tight Tank Grease Trap
(_ ] Other (describe): ____.___ _.
4. Effluent Tee filter resent?
p Ell " YF's o If yes, was ,t cleaned? " YesfWc
5. Observed condition of cornpon nt p,_,mP..V:
6. 5ystern Pyrnibed ray, �
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7. Location where contents vvere disposed
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S,gn,a(urea or E),atra
Sirdnature of F•ke;e.c.w{,ry F 3cility (or altaoh fEaC;ilify receipt) C7<'atr;
t5forr'n4.doc, 11/12 Sysyt(sr'n Purnping Recorrj n,ar e 1 <rr 1