HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 160 CARLTON LANE 9/9/2025 Commonwealth of Massachusetts Town of Ncrth Andover
City/Town of AjidL, ve r
- 22026
MAR
System Pumping Record
Form 4
Heal Qq,
DEP has provided this form for use by local Boards of Health. Other for lmlsIn
information must be substantially the same as that provided here. Before using this form, 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 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, J '
use only the tab &-- _ ------------ .........
key to move your Address
cursor-do not S�"
u the return use --,AP6Y e-...-..-1 ------ 1p"dod- —e---
key. City/Town State
2. System Owner:
--
Name
............................. -----------
Address(if
different from location)
-s._.tate- Zip Code
Teep�hone urn er
B. Pumping Record
,,-1.-,Y,,,
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: El Cesspool(s) ERI"Septic Tank El Tight Tank El Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? Fj Yes E5No If yes, was it cleaned? R Yes R No
5. Observed condition of component pumped:
6. System Pumped By:
L07 7/ 6
f�r G '..,aN rrl—--------------------
I - ----------------------------I——----------------------------------- -------------------
Name Vehicle License Number
Company 7
7. Location where contents were disposed:
..............................
—2- ............
............
Si nature Of auler Date
signature of ving Facility(or attach facility receipt) Date
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