HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 8 ADRIAN STREET 11/5/2025 Commonwealth of Massachusetts Town Of North Andover
City/Town of rFAoi d over MAR
-22026
System Pumping Record
Form 4 Healtil D
DEP has provided this form for use by local Boards of Health. Other forms may be used, Qjftent
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, -
use only the tab s............A ...........................
key to move your Address
cursor-do not A A-)
use the return
key. City own State Zip Code
2. System Owner:
Name
............................................. ----------------
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component: El Cesspool(s) 9Septic Tank F-1 Tight Tank ❑ Grease Trap
0 Other(describe): ------
4. Effluent Tee Filter present? E] Yes �No If yes, was it cleaned? r-j Yes F-1 No
5. Observed condition of component pumped:
6. System Pumped By:
7 7-P)-e-�-�-- ----w C)
Name Vehicle License Number
Company
M. 0
-i "I
7. Location where ntents were disposed:
- ------------- -—------------------ ----------
Signature Hauler Date
—------------------------ -----------------
Signature of Receiving Facility(or attach facility receipt) Date
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