HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 78 SPRING HILL ROAD 7/24/2026 Commonwealth of Massachusetts f North Andover
City/Town of
SYMOMI (Pumping Record AUG -4 2026
Form 4
Health Department
DEP has provided this form for use by local Boards of Health. Other farms May be u d, but the
information Must be substantially the same as that provided here. Before using this form check with your
fO so
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
k"POrtant:When
filling out forms I. System Location:
on the computer,
use only the tab 18- S
key to move your
cursor-do not
use the return
key. CltvwawnState"A
2. System —Zi P Code—
c"�er.
Name
Address(if different from location)
State
ilip Code
B. Pumping Record Telephone Number
I. Date Of Pumping
oate - 2. Quantity Pumped:
3. Component mall 0 Cesspool(s) Septic Tank
0 Other(describe): El right Tank 0 Grease Trap
4. Effluent Tee Filter present? 0 Yes El No If Yes, was it cleaned? 0 Yes F-1 No
5. Observed condition Of Component Pumped*
6. System Pumped By:
Name ......... 1fj
X2 —Ve4iei
�cense Number
Company
7. Locatio where contents were disposed:
Sign of Hauler —I- mace----------
-
'JIM"dwTe Or KOCOMnq Facility For a�ftachWk receipt)
I Gate
WomAdoc-11/12
System Pumping Record•Page 1 of 1