HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 182 RALEIGH TAVERN LANE 6/17/2026 Tl-.
Cmo omnwealth of Massachusetts Town of Nor�h Andover
City/Town of
JUL 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,
use only the tab 6� V
-----------
key to move your Address
cursor-do not
use the return ...........
key. City/Town State Zip Code
2. System Owner:
VQ
-Name
Address(K different from location)
City/Town State Zip Code
------------ ......... ----------
Telephone Number
B. Pumping Record
1. Date of Pumping anfi 2. Quty Pumped:
Date Gallons
3. Component: Q Cesspool(- Septic Tank Tight Tank ® grease Trap
Other (describe): ............ ...............
4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? M Yes M No
5. Observed condition of coTponent pumped:
(150o
6. System Pumped By:
----------- -------------
Name Vehicle License Number
---- O--f a"4 z
Company . zk-S---------� -e-,OPC-
7. Location wher con ten s were disposed:
71,
Signature.- -0.60 Date
-Receiving--- F-----------a'dI it y(or
-- --- - Daie
' -------
Signature of
t5form4.doc-11/12 System Pumping Record-Page 1 of 1