HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 767 JOHNSON STREET 4/8/2026 Town of Nofth Andover
_ Commonwealth of Mlessachusetts APR 13 2026
& w City/Town of
System Pumping Record r
Form 4
DEP has provided this form for use by focal Boards of Health. Other forms may be used, but the
information must be substantialiy the sarne 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 Io
the local Board of Health or other approving authority vvithin 1/1 days from the pumping date, In
accordance with 310 CMR 15,351,
_.
k _. _�y
f-6otJ� . front hick r a Ir_frt
A. Facility information E,UII_DING. front bark side rearr.fi riht
Important; Whirr
DECK. under
Mling out forms 1. Systern Location',
or)the cornf,7WW,
use only the tab
key to move yctr,r /,ddre s
cursor-return
rni m MA
i.,se the returrr _. _.___ :_.........
key Y ate Zip Code
2. S � 0wner'.
y ,
_ Name
morn ,y
Address (If different from location)
MA
Zif� Code
Telephone Nurr7kaf=r
B. Pumping Record
1. Date of Pumping _ _ _ ____._-- 2. Ouantity Pumped _ t—
Gallons
3, Component: ❑ Cesspool(s) C- eptic Tank (. J Tight Tank ❑ Grease Trap
❑ Other (describe): ........_ _____._._ _._.._
4. Effluent Tee Filter present? F] Yes o If yes, was it cleaned'? [_] Yes NO
(_
5. Observed condition of cornpone rt pu+ripgd
6, LNarne
per_i By,
Mass 1AA96E Mass 1AD31Z
erprises, Inc
Company
7. Lo, ion whe e ont nts were c?.isposecl:
..w
S D "` )
Slt�nature of f-trainer Date _........... _
Signature of F2cr„ew6ng (or atlach facility rerceif>1) Date
t5form4.doc- 11/12 Sy;atern Pornping Record Marge 1 of 1