HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 111 BROOKVIEW DRIVE 6/26/2025 lbwn of North Andover
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KA Commonwealth of . assachusetts 20?6
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City/Town of N &w,(-
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I -wk System Pumping Record Heajl-
( , ,Partment
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Form 4
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 hi
--------
key to move your A7dess
cursor-do not
JJ
use the return ...... ---------....------
key. City/Town State Zip Code
2. System Owner:
(kaie4 lzckh land
Name
--------------- -----------
Address(if different from location)
State Zip Code
- -
Telephone Number
B. Pumping Record
(.0 (40 1_j
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: F] Cesspool(s) 21*'Septic Tank R Tight Tank M Grease Trap
n Other(describe): ............. ---------- --------------------------------------........
4. Effluent Tee Filter present? n Yes [ rNo If yes, was it cleaned? n Yes n No
5. Observed condition of component pumped:
Good
6. �em Pumped By:
ard
----------------- - - -----------------
Name ' Vehicle License Number
(0;6rd., Sem H-ea;'161
.....................
Company
7. Location where contents were disposed:
atnof Hauler
10�
Signatur
-' Date
i—ivn --------------- — ----- Dateecig Facility(or
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