HomeMy WebLinkAbout- - Septic Pumping Slip - 491 SALEM STREET 8/18/2026 Commonwealth of Massachusetts Town of North Andover
-ra City/Town of SEP 14 2020
=- System Pumping Record
F o rrn 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 Sarre 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.
side r e a l e L, t
HOUSE: rout ba
A. Facility Information BUILDING: front back side rear left right
Important:When
DECK: under
filling out forms 1. System Location.
on the computer,
use only the tab _- 1_1o__ c �a 3 "
key to move your Address
cursor-do notIIi MA
use the return ____ __......_._.._._ _. _-_.__.____._ __..__.____.,..
key. CityfTown State Zip Code
(( 2. System Owner:
ame _____
Address(if different from location)
MA
Cityfl own State Zip Code
/..._ _.._._ _____—_ __..
Telephoneumber
B. Pumping Record
1. Date of Pumping aa1e 2. Quantity Pumped: Gallons
3, Component: Cesspool(s) eptic 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 cornponent pumped:
6.CNarne
iped By: `e
..__._..__.__._ Mass 1AA95E Mass '1AD31Z
Vehicle License Numbe
terprises, Inc _ _............
7. Lac on whet n nt ate disposed
G SD . .m
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) bate
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