HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 121 RALEIGH TAVERN LANE 6/16/2026 gown of North Andover
Commonwealth of Massachusetts
City/Town of r JUN 1 2026
System Pumping 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 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 Information
Important:When
filling out forms 1. System Location:
on the computer,
useonly the tab ---1. 11............... ...........L-W-------------------- -—--—---------------------------------
key to move your Address F
-----------------------------
cursor-do not
use the return
key. City[Town State Zip Code
2. System Owner:
el
(A..\*t ----------
Name
'Aid--dress(if different from location)
.................................... ..................................................
State Zip Code
----------
Telephone Number
B. Pumping Record
1. Date of Pumping D..ate Quantity Pumped: -Gallons. . ----------
3. Component: F1 Cesspool(s) EZKSeptic Tank F-1 Tight Tank R Grease Trap
M Other(describe): ............ ---------- ------
4. Effluent Tee Filter present? 0 Yes No If yes, was it cleaned? Yes R No
5. Observed condition of component pumped:
6. System Pumped By:
--------------- ------ -------------------------- .................. ---------
Name Vehicle License Number
.'TCompany
7. Location where contents were disposed:
------- ........... ...........
------------------------------------ --- .
-------------e
L/
---— --- -- ----------------
i e of ule Date
--- ., .� ......... ................................. 11..................... ------------------------------------- ------------------------------ ----------
Signatureof Receivirr iffify(or attach facility receipt) Date
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