HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 82 LIBERTY STREET 6/19/2026 Commonwealth of Massachusetts Town of North Andover
City/Town of qr�e-v, JUN 2 9 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 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, '7�
use only the tab
ic:il
key to move your Address
cursor-do not
use the return
key. City/Ton
State i—
Zip Cade
2. S stem Owner:
Name
nrmm
Address(if different—from�location)
-&'�YlTown���
State Zip Cade
Es. Pumping Record -- Telephone Number
I. Date of Pumping
Date 2,, Quantity Pumped:
3. Component: 0 Cesspool(s) Septic Tank E] Tight Tank n Grease Trap
El Other(describe):
4. Effluent Tee Filter present? 0 Yes 0 Na If yes, was it cleaned? ❑ Yes 0 No
5. Observed condition Of component Pumped:
6. ASyeM Pumped By:
I C
erne
Vehicle Ucense
Company��'����.
7. Lo bon where contents were disposed:
Sign Hauler
Dates
Signature of Receiving Facility(or attach�faciiity receipt}— -Date ---------
—
t5fdrnA.doc-11/12
System Pumping Record
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