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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 226 ABBOTT STREET 6/26/2025 "Town of Nort�Andover Commonwealth of Massachusetts City/Town of 2 2026 A-r dowj MAR 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 �)Wo ............. .......... ............. ---------------------------------------------------------- key to move your Address cursor-do not use the return key. City/Town State Zip Code 2. System Owner: am Address(if different from location) l -- ---------------- -"' ----------- City/Town State Zip Code ---—-----------------------------........... Telephone Number B. Pumping Record 1. Date of Pumping -1 Date I I 2. Quantity Pumped: Gallons 3. Component: ❑ Cesspool(s) U/Septic Tank El Tight Tank F-1 Grease Trap ❑ Other(describe): ------------....... 4. Effluent Tee Filter present? F] Yes 2-`No If yes, was it cleaned? © Yes n No 5. Observed condition of component pumped: --&— ---- —-------------- --------- .............. 6. System Pumped By: Name V ehic'l-e-License-Number Company 7. Location wh contents were disposed: ocation whe ............. ..................................................... -------. -- ---------- ..............- .................... ......... Signa 0 f au le er Date Signature, d vt-hd F.acility-(or attachfacility receipt)--------- -Date- t5form4.doc-11/12 System Pumping Record-Page 1 of 1