HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 301 SUMMER STREET 12/8/2025 Town of North Commonwealth of Massachusetts Andover
City/Town of L,j
System Pumping Record DEC 15 '2025
Form 4 Health Department DEP has Provided this form for use by local Boards of Health. Other forms may be used the
information must be substantially the same as that Provided here. Before using this form, but, 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 I. System Location:
on the computer, 2
use only the tab
key to move your Address
cursor-do not
I A
use the return "r i—�
key. CRY/rown Skate Zip c7ode-----
2. S stem Owner
Q1X �.-
Rame
Address(if ditferenk from k�atban)
Skate
Zip
Code
PUmpinq Record Telephone Number
----
1. Date Of Pumping
2. Quantity Pumped:
3. Component: Cl Cesspool(s) Septic Tank D right
0 Other(describe): Tank D Grease Trap
4. Effluent Tee Filter present? C] Yes n No If yes, was it cleaned? D Yes Q No
5. Observed condition Of component Pumped:
6. S e,
n Pumped By:
Name
Vehicle License Number �
4-any
7. MLOC 'on where contents were disposed:
L
L
Sign re" f Hauler Date
Signature of Receiving Facility(or—attach facilky—rec—eipt) l pate
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System Pumping Record Page 1 of I