HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1044 SALEM STREET 6/17/2025 Town of North Andover
Commonwealth of Massachusetts
City/Town of b Nbz�pet MAR - 2 2026
System Pumping Record Healt
h Department
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 '��3keV)
------------- ..................................... ------------ ................ -------
key to move your Address
cursor-do not
use the return
............. .. ..........
key. City/Town State Zip Code
2. System Owner:
............ -------------- ------------------------
Name
----------- ---------- ------------------------------ —--------
Address(if different from location)
...........
City/Town State Zip Code
Telephone----- -Number--------------- ----------
B. Pumping Record M0
1. Date of Pumping 2. Quantity Pumped: .......—--------
Date Gallons
3. Component: F1 Cesspool(s) 2/septic Tank R Tight Tank R Grease Trap
R Other(describe): ---------------------
4. Effluent Tee Filter present? E] Yes JO/No If yes, was it cleaned? R Yes R No
5. Observed condition of component pumped:
—------------------ --------------------
6. System Pumped By:
zrd M)(OQ 1-1(D
--------................... ............------------------------- .. ................
Name Vehicle License Number
p�
Company
7. Location w contents were disposed:
Location
-----------------............
Signature o aule Date
----------------------- -Signature ------------
-Facility(or attach facility receipt) Date
"''-of-R--ecei'i'
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