HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 55 SOUTH BRADFORD STREET 2/20/2026 Commonwealth of Massachusetts
City/Town of
System Pumping Record
LL Form 4
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 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 j
key to move your Address
cursor-do not
v,
use the return L
k� V
key. uity/Town
Mate Zip Code
2. System Owner:
o cl�'
Name
Address(if different from location)
Z�t /—Town Mate Tip-Code
—
Telephone Number
--�—
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Component: CeSSP001(s) Septic Tank ❑ Tight Tank 7 Grease Trap
7 Other(describe):
4. Effluent Tee Filter present? [] Yes No If Yes, was it cleaned? 7 Yes No
5. Observed condition of component Pumped:
c�
6. System Pumped By:
o
Name Vehicle License Number
Wayne's Drains, Inc.
company Town of North Andover
7, Location where contents were disposed:
I A In9C
Signature of Hauler Date Health DepartMent
Signature of Receiving Facility(or attach facility—receipt) Date
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