HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 221 BOXFORD STREET 6/17/2025 Tbwn of No�h Andover
�L\ Commonwealth of Massachusetts
--- MAR
City/Town of�jo(N^ &Pm \or - 2 2026
..........
System Pumping Record
Form 4 HO'afth 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 --P\ �)ChJ60 .......
key to move your Address
cursor-do not 6184
use the return
key. City/Town State Zip Code
2. System Owner:
. .......... -----------
Name
---------------- -------
Address(if different from location)
-----------
Cit own State Zip Code
................... -------------
Telephone Number
B. Pumping Record
/coo
1. Date of Pumping Da.te ----------- 2. Quantity Pumped: Gallons
3. Component: n Cesspool(s) [1--'Septic Tank 0 Tight Tank n Grease Trap
❑ Other(describe): ....................................... .................. ------- .............
4. Effluent Tee Filter present? n Yes ❑No If yes,was it cleaned? n Yes n No
5. Observed co dition of component pumped:
.............. ------ ... .....-I-1.............. -----------
6. System Pumped By:
Vehicle License Number
Name
ft' SAA 014V�Ifj
Company
7. Location where contents were disposed:
---------------- ---------------------------- .....-------------- .................
---------------........
-------------
re, Haul�er Date
Sig
............ ---------------------------
Signature of Receiving Facility(or attach facility receipt) Date
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