HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 134 CROSSBOW LANE 6/26/2025 lown of No�h Andover
11\ Commonwealth of Massachusetts MAR 2 2026
City/Town of /Vtr+�
System Pumping Record
Form 4 L)eP,9rhent
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,
useonly the tab -13H. . ............ . --------------------- ..................... --------------------- ---5 ...............
key to move your Address
cursor-do not /U -kk
use the return � -At .............
key. City/Town State Zip Code
2. System Owner:
VQ
Name
—-----....... --------------------------------------- .......................
Address(if different from location)
--------------------------- ------------------------------- ...... .................
City/Town State Zip Code
..................
Telephone Number
B. Pumping Record
1. Date of Pumping Date
2. Quantity Pumped: 1.G..Gallons
-----------------
3. Component: F� Cesspool(s) R"Septic Tank F1 Tight Tank M Grease Trap
❑ Other(describe): ................................ ..............------------------ ...........
4. Effluent Tee Filter present? n Yes 2-.N' o If yes, was it cleaned? r-1 Yes ❑ No
5. Observed copdition of component pumped:
.............. ...............
6. System Pumped By:
......................
vehicle License Number
P/L'(Ms, 1-14r,
---------------
Company
7. Location where contents were disposed:
(VL-
, .
........... ............. ............................------------------------------------------------ -----------------------------------------
Si n Hauler Date
................ ------------------- ............... ......
-
Signature..' o eceiving Facility r attach facility receipt) Date
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