HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 95 OLYMPIC LANE 4/21/2026 Commonwealth of Massachusetts TOWn of North Andaver
City/Town of MAY pin -4 2026
System Pumg Record
Form 4 Health Department
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 fo
rm, 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 Address
cursor-do not
use the return
key. Cityfrown
S�tate ��-
2. System Owner: Zip Code
Name
Address(If different from location)
City
21P 6;a-
6
;p—hon�;e--N�-uin—ibe r—
*—Pum—P1n—g telephone
Te";
I. Date Of Pumping
L
Date 2. Quantity Pumped:
3. Component: rron
n CeSSPOOI(s) ED Septic Tank El right Tank Grease Trap
El Other(describe): ------
4. Effluent Tee Filter present? El Yes n No If Yes, was it cleaned? 0 Yes n No
5. Observed condition Of component Pumped:
—------------------------
6. System Pumped By:
N a
VehicleUcens�e Numb-
r
Company
7. Location where contents were disposed:
G L 17)
sign f
U1 r
Ce7--
Ipt) j --
Signature of Race ing Facil'It'y(or attach ia—cifity—re Date
t5fbM14-d0c- 11/12
System Pumping Record-Page 1 of 1