HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 125 SAW MILL ROAD 4/16/2026 Commonwealth of Massachusetts Town of North Andover
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City/Town of jV,0U-,Vh "
JUN 15 2026
System Pumping Record
-------... Form 4 Health D
gqMDEP has provided this form for use by local Boards of Health. Other forms may belle I ent
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,
use only the tab
key to move your Address
cursor-do not e Amjovtr
use the return
key. City/Town State Zip Code
2. System Owner:
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...............
Name
.............................................. .......... ................
Address(if different from location)
City/Town-- --' "S-t"-a-t-e----- Zip-Code-
............
Telephone Number---
B. Pumping Record IQ, Ov
1. Date of Pumping D ate 2. Quantity Pumped: G-a I.I-o.n-s,I ---------------......................
3. Component: F-1 Cesspool(s) [9--Septic Tank FI Tight Tank F] Grease Trap
❑ Other(describe): —-------------.1........... ——---------------------- ----------
4. Effluent Tee Filter present? R Yes [12/No If yes, was it cleaned? Fj Yes F-1 No
5. Observed condition of component pumped:
6. System Pumped By:
ir6 q 1 -10
T-�� I ................... ----------------
Name Vehicle License Number
A.
------------ -------
Company
7. Location where contents were disposed:
.................... .................................. -------------.................. ..............................
U?
...................
S3 i a ti of ule Date
Signature of Receiving Facility(or attach facility receipt) Date
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