HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 45 SUGARCANE LANE 6/26/2026 Commonwealth of Massachusetts Town of North Andover
City/Town of
System Pumping Record JUL -12026
Form 4
D E P has provided this form for use by local Boards of Health. Other K"W* t
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 CM R 15.351
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab .......
key to move your Address
cursor-do not
use the return ------....................
key. CityfTown State Zip Code
2. System Owner: c.e9le, ...........
Name
-------------
Address-'-(if-different--f-r—omoo-c-ition)
CityProrvn State Zip Code
............
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped,
Date Gallons
3. Component- F-1 Cesspool�) [3"Septic Tan"k, [I Tight Tank ❑ Grease Trap
Other(describe)
4. Effluent Tee Filter present? n Yes 1�10 If yes, was it cleaned? Yes El No
- —""' F1
5, Observed condition of component pumped:
— -------- --------------------------- - -------------- - ----
6. System Pumped By:
.......... ...........-------
Name Vehicle License Number
Company
7- Location where contents were disposed:
...........
Signature of Hafiler Date
.......
1-
....
"Signature
............-- -.---...........
of Receiving Facility(or attach facility receipt) Date
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