HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 434 BOXFORD STREET 7/21/2026 �
Commonwealth of Massachusetts in of North Andover
c u City/Town of JUL '1 2026
System Pumping- Y in p g Record
Y
:. Form 4- � �C � 'h 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. Facilit Information BUILDING: nt ack side rear eft fight
front back side rear left right
Important:When DECK: under
use oni e tab m Location'.
on computer,
filling or 1. YSt
y th --
��
key to move your Address
cursor-do not MA _
use the return key. City/Town— State — �— Zip Code
2. System Owner:
Name .---._.._.._____.-------
Add ress(If different from location)
MA
City/Town St at Zip Code
Telephone Number
B. Pimping Record
1. Date of Pumping -`- - — 2. Quantity Pumped: ------ -
p g Date Y p Gallons
3. Component: ❑ Cesspool(s) e'ptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. Sy tem Pumped By:
D ve Tined_____�_�_ __.___.____._.___ Mass 1AA95E ss 1AD31Z _
N me Vehicle License Number
Ba Inter prises, Inc.
Co pang --
7. cation where onten re sb'd:
GL
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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