HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 42 JERAD PLACE 4/28/2026 Town of No�h Andover
Commonwealth of Massachusetts
- _- 15
City/Town of -,IVOC41) 4,r&tr JUN 2026
System Pumping Record ea H
Form 4 Ith DepartMeilt
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, C1
use only the tab ................
key to move your Address
cursor-do not
use the return 4qi0 -------
key. City/Town State Zip Code
2. System Owner:
VQ f'a V,6
-T- --- --- ................... ......................
Name
-----------
different from location)
-City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2 Quantity Pumped:
Date Gallons
3. Component: F-1 Cesspool(s) P/Septic Tank F-1 Tight Tank F-1 Grease Trap
ROther(describe): ------- ........................ ......................................... ...........................
4. Effluent Tee Filter present? R Yes No If yes, was it cleaned? M Yes F-1 No
5. Observe
d condifign of component pumped:
-----------6 — ------- ------------------------------------- ------
6. System Pumped By:
Vehicle License Number
A�4
Company
7. Location where contents were disposed:
9 / 2 &' 12-W
Signature of Hauler Date
--------------------------------
Signature of Receiving Facility(or attach facility receipt) Date
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