HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 21 APPLETON STREET 8/12/2025 I Town of North AndOver
Commonwealth of Massachusetts
.......... MAR
City/Townof A�hclw-P-C' - 22026
fln
System Pumping Record
...................
Form 4 Health
D"Partment
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 Locat' LJV
on the computer, 1 4e
use only the tab -----------
key to move your Address
cursor-do not "U1,
use the return M- 1-4-n----4N.24 0 W -----
key. City/Town state Zip Code
2. System Owner:
'7—o I .......... ------ .......................................... .............
Name
............. ........................... -----------
Address(if different from location)
CRiifo'wh' State Zip Code
- ----
...................
Telephone Number
B. Pumping Record (k
1. Date of Pumping ------------
Z. Quantity Pumped: ------
Date Gallons
3. Component: F] Cesspool(s) M Septic Tank R Tight Tank F-1 Grease Trap
M Other(describe): -- .1-1-111--..............................
4. Effluent Tee Filter present? 0 Yes 2 No If If yes, was it cleaned? ❑ Yes F-1 No
5. Observed c ndition of component pumped:
................. ---------------- .............................
6. System Pumped By:
N--A............
..........
Vehicle License Number
----------- ...................
Company
7. Location where contents were disposed:
--------------- -------- -------------- -----------
............... ...........
re of H ler Date
...........
Signature of Receiving Facility(or attach facility receipt) Date
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