HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 1116 SALEM STREET 11/20/2025 Commonwealth of Massachusetts TOWn of North AndoVer
City/Town of
System Pumping record NOV 2 120?5
Form 4
oar
DFP has provided this form for use by focal Boards of Health. Other forms rn)W W - �►
information must be substantially the sarne as that provided here. Before using this form, check Iwq 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
HOUSE: front bar. d re IE_=ft M. rf ht
A. Facility Information BUILDING: front back side rear left ritr,t.
Important:When DECK: under"
filling out forms 1. Syst Ocati
on the computer,
use only the tab __
key to move your Address
cursor-do not MA
use the: return --_____ __.__._ .__.._._.___.___ .�__�__...._.._..__________.-..___ _
key. Cityrfown State Zip Code
Sy terr7
No ma weer:
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SS
Address (if different from location)
MA
City170 ri .. State
A
Telephone Number ._..._
B. Pumping Record
1. Date of Pumping pate -__LL ____._ ._.._..__ 2. Quantity Pumped:
Gallons
3, Component: ] Cesspools) [U--a ptic Tank ❑ Tight Tank g ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes U1<0 If yes, was it cleaned? ❑ Yes CJ No
5. Observed condition of component um e,
6, SPfeson
sped By:
D Mass 1AA95E ass 1 A C _
NVehicle t_icense Nurn. ,r
Berprises, Inc._ w. _ __._. .
Company
7. t0�Dl
ntents were disposed:
..
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Cate
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