HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1635 OSGOOD STREET 5/19/2026 Commonwealth of Massachusetts Town of Nodh Andover
CitY/Town of L�. 4�, NA,, ,
MAY 2 6 2026
System Pumpin ec
g Rord
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 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 CIVIR 15.351.
A. Facility_Infdrmat_io`n__--------______
llwdant:When
filling out forms 1. System Location:
On the computer, ( (
use Only the tab Ci 9
key to move your dress;
cursor-do not
use the return
_(3 7gy—/—TN
key, own W�r
estate
41D 2. System OwnerZip Cie
94
Address(if different
_61�tWown
ry State
Zip Code---
B. Pumping Record
1. Date of pumping
Date 2. Quantity Pumped:
3. Component: 0 CesspoolsGallons
Other(describe): ( ) Septic Tank 0 Tight Tank 0 Grease Trap
----------------------------
4. Effluent Tee Filter Present? 0 yes Ej Na If yes, was it Cleaned? D Yes 0 No
5- Observed condition Of Component Pumped:
6. Sys pumped BY:
Urn By:
Na A, -----------
Vehicle
Company
om any
7. Location where contents were disposed:
Sign re of Hauler
Signature of Receiving Facility(or attach facility receipt)
Date
t*M)4.dOc-11/12
System Pumping Record»Page 1 of 1