HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 97 FOREST STREET 6/12/2026 Commonwealth of Massachusetts Town of North Andover
go City/Town of
JUL -6 2026
A 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 CIVIR 15.351.
HOUSE: front backside rear hi�W right
A. Facility Information BUILDING: front back side rear left
Important:When DECK: under
filling out forms 1. System Location:
on the computer,
use only the tab q-7
key to move your Address®
cursor-do not A�o MA
use the return —------
key. City/Town State Zip Code
&� 2. System Owner:
Vr—tL
4' Name
Address(if different from location)
MA
City/Town State Zi Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component: 7 Cesspool(s) (D,,-Septic Tank 7 Tight Tank 7 Grease Trap
F-1 Other(describe):
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? F Yes D No
5. Observed condition f MT.0Anen um e
L...
on I ion o cq , a
6. S stem Pumped By:
ave Tin Mass 1AA95E Mass 1AD31Z
ame Vehicle License Number
son
on Enter rises, inc.
Company
r A
7. ati n wher contents were disposed:
LS
G
Signature of Hauler-- Date
_Signature of Receiving Facility—(or attach--facility receipt) Date
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