HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 85 COLONIAL AVENUE 7/15/2025 Commonwealth of Massachusetts Town of North Andover
F City/Town of
MAR - 2 2026
& System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other 4r*UPb n
information must be substantially the same as that provided here. Before using this form, check wit 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 A-S
key to move your Address
cursor-do not
use the return -A0 ----------
key. City/Town State Zip Code
2. System Owner:
J` ..................................
... ................ -----------
Name
Address(If different from location)
stale'. Zip C de
Telephone Number
B. Pumping Record
1. Date of Pumping Da 2. Quantity Pumped: Gauons
te
3. Component: El Cesspool(s) [9ooSeptic Tank R Tight Tank Ej Grease Trap
El Other(describe): ------------------- ............ .......... -------—-----------------
I','
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? F-1 Yes R No
5. Observed condi jon of component pumped:
6. System Pumped By:
Name Vehicle License Nu ber
7. Location where contents were disposed:
Q-2 .......
Sig ur o Hauler. Date
"g
.............. ............
r6-cf
Si natures--ece tng""F6cility(or attach facility receipt) Date
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