HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 915 JOHNSON STREET 3/2/2026 Town of North Andover
Commonwealth of assachusetts
City/Town of q",( MAR 2 2026
System Pumping Record
Form 4 Health 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,
use only the tab --------
key to move your Address
cursor-do not AAN
use the return /kh
key. City/Town ....... -State Zip Code
VQ 2. System Owner:
---------------------------
Name
............. ----—--------------------------------------- --- - -------------------------------------
Address(if different from location)
City/Town State Zp Cade
T e i a p_33ti_bar
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Ga_llo_ns_
3. Component: F] Cesspool(s) M Septic Tank M Tight Tank F-1 Grease Trap
F-1 Other(describe): '_._''__'_'_—---------
4. Effluent Tee Filter present? [:] Yes [2/N 1 0 If yes,was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
---------- ------
6. System Pumped By:
...y' 1°� -f� -�— ^- -T�� - - . ... .................-------
Name Vehicle Lis
Company -ease Number
/V
�_
7. Location where contents were disposed:
--------...........................................................................................
------- ----- -------------------------------------------------------------......-
Sign r 117a�uer Date
Signature or, iving Facility(or attach facility receipt) Date
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