HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 43 MILL ROAD 4/8/2026 t
Commonwealthf North Andover
of Town ��...
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L System
Pumping 1:3
2026
Form 4
H
DEP has prodded this form for use b Health Department
y local Boards of Health
information must be substantiallyt . ether forms may be used, but the
focal Boar he same as that provided here. Before using this d of Health to determine the form the use. The 9 h farm, check with your
the local Board of Health or other ' y . System Pumping Record must be submitted to
accordance with 3 aPPro�ing authority within 14 days from the Pumping date '
' 0 CMR 15.351. P 9 In
A. Facility inform--ation
Important:when
filling out forms I. System Location:
on the computer,
use only the tab \L
key to move your Address
cursor-do not .
use the return
City/To
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'_Key- ai•pw
,+ state Y`
2. System Owner: dip Code
Edmadax SIV*
Name
arm
Address(if different from location) .
Cityfrown
t State dip Code
t
Bet PumpingRecordTelephone Number .
I. Date of Pumping
*Dae 2. Quantity Pumped:
allons
3. Component: El Cesspool(s) Septic� ept�c Tank right ht Tan
. � k El grease Trap
Other{describe}:
4. Effluent Tee Filter presents d Yes No
� If yes,was it cleaned?? •❑ Yes El Na
5. Observed condition of component um ed:
p p
• .rvrtr�.. za'ay;: '" .--. -r r r,w+r yr � sr r e
r+
5. Syst PUm ed B :
p y
N
e
Vehicle License Number
Company
7. Location where contents were disposed:
,.
L .
t
Sign �
of Hauler a
C Date _
if
Signature of Receiving Facility(or attach facility receipts Date y _
4
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E System Pumping Record e Page 1 of i
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