HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 415 SALEM STREET 9/17/2025 Commonwealth of �7 Massach7 setts Town of N"orth Andover
City/Town of
A � "Ir" 2026
System Pumping Record
Form 4
He(e,1,1th, Departient
DEP has provided this form for use by local Boards of Health. Other forms may be used, but t tp e
information must be substantially the same as that provided here. Before using 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 Location:
on the computer,
use only the tab 0
-------------
key to move your AVdre,,ss
cursor-do not
use the return
key. City/Town State Zip Code
2. System Owner'.
04
Name
-------------------------- -—---------- ..........
Address(if different from location)
----------------------
City/Town State Zip Code
................. _ 7
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped: ............ ---
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank El Tight Tank F-1 Grease Trap
❑ Other(describe): .............. ...................................................................-----------
4. Effluent Tee Filter present? 5211Yes D No If yes, was it cleaned? 9,Yes D No
5. Observed conditipn of component pumped:
.......... ---------- ........................................... --------...........................................
6. tem Pumped By:
.......................................... ------ ----------- ------
ame Vehicle License Nutnber
Company
7. Location where contents were disposed.-
------------- -_----------
----------------------
16n ure of uler Date
Signature 471 eceiv'i n--g,--F,-a—cil-i-t-y--(-o-r--a-tt-a-c-h--f"a"cility receipt) Date
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