HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 212 GRAY STREET 11/5/2025 TOvv'n Of Nbrth Andover
L\ Commonwealth of Massachusetts
City/Town of Akj-. Ayxt,,4'\xr MAR - 2 2026
System Pumping Record
Form 4H Oepartment
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 CMR 15.351,
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, c"N
use only the tab t c 4
--------------
key to move your Address
cursor-do not _.A-ALA ................
-Ci Crown §'t-ate ------------- Zi.-p Code
use the return
key.
VQ 2. System Owner:
i............... ------------- ----------------------
Name
- -—------------------ .................---------------—--------------------------- ---------------
Address(if different from location)
CityCl own State Zip Code
97J-- 7(ef-
Telephone Number
B. Pumping Record 1) r-
11 -'�b C>
1. Date of Pumping Date ..............--- 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) K],/Septic Tank ❑ Tight Tank R Grease Trap
M Other(describe): ------------------------- ............. .........-
4. Effluent Tee Filter present? R Yes Eilq'o' If yes,was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
-------------------
6. System Pumped By:
......................... --------------
Name Vehicle License Number
rd
Company
7. Location whey co tents were disposed:
----------
- -----------
Si g re Hauler Date
---------- ----------- ------------------------
Signature of Receiving Facility(or attach facility receipt) Date
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