HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 163 FARNUM STREET 6/12/2026 RJRCommonwealth of Massachusetts Town of North Andover
City/Town of
System Pumping Record JUN 16 2026
Form 4
DEP has Provided this form for use by local Boards of Health. Other Heaformslth Department
information must be substantially the same ma as that Provided here. Before using this form, check with
y be used, but the 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.
4—" Fa—cil—ity—Inf—o,,—nati—on--------------_
Important:When
filling out forms 1. System Location:
on the computer, I "I r-'
use Only the tab
key to move your Addre
cursor
-do not
use the return
key. City/Town
Vf r.-
state -
VQ 2. System Owner: ZIP C�Ode --
one
Address(if different from location)
'6'iif�rown ���-----------
tate Y,�'Code—
B. Pumping Reco -Fe—lephone j4-ue—r
1. Date Of Pumping
2. QuantityPurnped:
3. Component:
0 Cesspool(s) Septic Tank 0 Tight Tank Grease Trap
El Other(describe): -------
4. Effluent Tee Filter present? IM Yes No if yes, was it cleaned? D Yes 0 No
5. Observed condition Of Component Pumped:
6. System Pumped By:
Na
Vehicle License Number
Company om pany
7. loco n where contents were disposed-.
L S'
Sign fMauler' '
Date
Signature of RRecm*e1Wving Facility,(&r—attach iacilit;7r—eceipti
t5lbrm4.doc-11/12
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