HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 130 CHRISTIAN WAY 11/26/2025 i
TON J� � orth Andover
1\- Commonwealth of Massachusetts
City/Town of Orti, 4
System Pumping Record MAR - 2 2026
Form 4
HealUjil rbent
DEP has provided this form for use by local Boards of Health. Other forms may Aw,
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 CMI;R 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab C tj r VJ
---- 111....... ............................. --------------------------- --------
key to move your Address
cursor-do not
use the return
key. City/Town State Zip Code
2. System Owner:
-------------........ -----------...... --------------............. —--
Name
Address(if different from location)
.......................................... --------------------- ------------------- -------
City/Town State Zip Code
c77X- (90�47 (0yG G
Telephone Number
B. Pumping Record
5 Z;0..................... ...............
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component: F Cesspool(s) [Septic Tank ❑ Tight Tank n Grease Trap
F-1 Other(describe): ------------
4. Effluent Tee Filter present? 0 Yes [9'No If yes, was it cleaned? ❑ Yes n No
5. Observed condition of component pumped:
6. System Pumped By:
..........................
::
Na me
Vehicle License Number
Company
7. Location where c ntents were disposed:
Sig ure -H -uler- Date
Signature ofR c irig-fiaili Fy(or attach facility receipt) Date
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