HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 97 COMMERCE WAY 5/4/2026 Commonwealth of Massachusetts
City/Town v\
System Pumping record
Form 4
IDEP has provided this form for use by local Boards of Health, Other formi maybe used, but the
information must be substantially tie same as that provided here. Before using this fbrm, 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 froe
pum d ofing ate In
nfh
accordance with 310 CMR 16,351., In North Andover
A. Facility Information
Important:When JUN 2 6 2026
filling out forms System Location:
on the computer,
Orr
Use only the tab
key to move your Address
cursor-do not
use the retu;
key, City/Town state Tip-Code
2. System Owner:
A0
Nate
Address(if different from location)
CitYf-rown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: cesspooi(s) Septic Tank 7 Tight Tank ❑ Grease Trap
F7 Other(describe):
4, Effluent Tee Filter present? 7 Yes F7 No If yes, was it cleaned? Yes No
5, Observed condition Of component Pumped:
c
6, System Pumped By:
0
Name Vehicle License Number
Wayne's Drains, ['no.
Company
7, Location where contents were disposed:
31 d0
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date