HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 843 JOHNSON STREET 7/15/2025 Commonwealth of Massachusetts Town of Nofth Andover
City/Town of A,/rk'Vr,,r
System Pumping Record MAR - 2 2026
Form 4
DEP has provided this form for use by local Boards of Health. Oth 16QaPlw4new
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 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab
key to move your Addr ss
cursor-do not
use the return
key. City/Town State Zip Code
2. System Owner:
VQ
KNAI t----------- -------
—Name
-------------
Address(if different from location)
-6-it—y/Town State Zip Code
Telephone Number
B. Pumping Record
Z
z>
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: F1 Cesspool(s) 2"Septic Tank F] Tight Tank R Grease Trap
❑ Other(describe): ---------
4. Effluent Tee Filter present? D Yes [3'-No If yes,was it cleaned? ❑ Yes n No
5. Observed con ition of component pumped:
6. System Pumped By:
f ......
"10me Vehicle License Number
Company
7. Location where contents were disposed:
Signat"re Hauler .-Date-. ............
S.
Signature aceiving Facility(or attach facility receipt) Date
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