HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 26 TURTLE LANE 5/29/2025 Commonwealth of Massachusetts I 01NA Of Nofth Andover
City/Town of Ly-w Ati dove,1r,
MAR -- 2 2026
System Pumping Record
Form 4 Heakh Department
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
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 CIVIR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, 0 (0 7-U-- L'an't
useonly the tab ------------...................... .....................-----------................-......................................
key to move your Address
cursor-do not A16rf-h 4-Adov-'er 0 1�N's
use the return
key. City/Town State Zip Code
2. System Owner:
Ar411A�r _1D U-11
Name
I----------------- ....................... ---------------------------------------------------------------------------------
Address(if different from location)
..........
City/Town State Zip Code
97
Telephone Number
B. Pumping Record
S, -j 2-q 1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) Er"Septic Tank F-1 Tight Tank Fj Grease Trap
MOther(describe): .................................. .........................................................................................
4. Effluent Tee Filter present? M Yes No If yes,was it cleaned? F] Yes R No
5. Observed condition of component pumped:
------------ -------
6. System Pumped By:
6 1 --- W(0 q(7
Name Vehicle License Number
Company
7. Location where contents were disposed:
---------- .............
r flad Si tu�reiiu- Date
u
- g r Receiving
Si-na ure of i��cei ng Facility(or attach facility receipt) Date
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