HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 172 SUMMER STREET 6/26/2025 Commonwealth of Massachusetts TbVfn of Nofth Andover
City/Town of LLrt
MAR - 2 2016
System Pumping Record
Form 4 HoaT") Departhent
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,
use only the tab 1`70
. ----------------------------------.......... ................--------------------------------------------------
key to move your Address
cursor-do not
use the return C r
—14-4,4- ....................................... ............
key. City/Town State Zip Code
2. System Owner:
Name
-- -- --------------------------------------- ....................... --------- ...........................
Address(if different from location)
-------------------Cityfrown State Zip Code
................. .........-----------------------------.............
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: F-1 Cesspool(s) Oseptic Tank ❑ Tight Tank F] Grease Trap
F-1 Other(describe): -.1--.......................------- ------------..................................................................
4. Effluent Tee Filter present? R Yes [9 Jo If yes,was it cleaned? F-1 Yes Fj No
5. Observed condition of component pumped:
6. System Pumped By:
.............. ----------- ...............—----------------------- ......
Vehicle License Number
Company
7. Location wh9re contents were disposed:
........... ...........
Date
Si t a f Hauler'
,s i tr
§Ign-a'tu _'f Receiving Facility(or attach facility receipt) Date
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