HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 327 FOREST STREET 6/29/2026 < Commonwealth of Massachusetts TOwn of North Andover
City/Town of
System Pumping Record JUL - 6 2026
Form 4
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DEP has provided this form for use by local Boards of Health. Other forms
information must be substantially the same as that provided here. Before using this form, check 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
........... -------
key to move your Address
cursor-do not /�j Au�k)< , r" MA
use the return - . . -- - � ......
---
key. town State Zip Code
2. System OwZer:
?_AzM_Z A yv"C
Name
Address(if different from location)
MA
City/To w---n- State lip lode
Telephone Number
B. Pumping Record
1. Date of Pumping -bate /1 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) ZSeptic Tank F-1 Tight Tank R Grease Trap
❑ Other(describe): ...................
4. Effluent Tee Filter present? 0,,Ygs R No If yes, was it cleaned? D-les [_1 No
5. Observed condition of component u, ped:
..........
6 Sy
tem"Pumped By: Z
a�mn e�
ave Tiney Mass 1AA95E Mass 1AD3
Vehicle License Nu4e�lr
son Enterprises, Inc.
Company- " - -
7.f-tocaton w4l c, tents ..,,,,,et posed:
............
Signature
ignature.11.of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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