HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 851 FOREST STREET 12/31/2025 Town f Noth Andover
,w f1161tag► Mt,-alLli �Ji yvI Ca Ct iI LA.
City/ `own of A 2026
Farm 4Health Department
information must be substantially the same as that provided here. Before using this Corm, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
0—1—~ [ ra,,�rrr f i-mnith nr ntbP-r:nnrnNAnn ai rthnrity within 14 days from the pumping date in
caccor'oanG- wan :J'iU ulvif-; i --jo i.
A Facility Infcarmation
Important:When
fining out farms 1. System Location: f c on the computer,
key to move your Address
cursor-do not o dtf t✓ w _ ___�_.
use the return
CotvfTowrn State Zip Code
2. System owner:
Address(if different from lacatian)
CityPfawn State Zip Cade
B. Pumping Record
[ a _ 31 - r
Date
3. Component: ❑ Cesspools (j!Septic Tank ❑ Tight Tank ❑ Grease Trap
4. Effluent Tee Filter prey �. Yes�p No if yes, was it cleaned?CEa No
5. Observed condihon of component pumped:
6. System Pumped By:
Name
Company
7. Location where contents were disposed:
Signature at Haulee —_._---
Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc-11/12 System Pumping Record-Page 1 of 1