HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 76 OLYMPIC LANE 7/30/2026 Town of North Andover
Commonwealth of Massachusetts
City/Town of SEP 8 2026
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 YOL
local Board of Health to determine the form they use.The System Pumping Record must be submitted tt
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 ordy the tab ------
key to move your Address
cursor-do not
use the return
key. State Zip Code
2. System Owner:
Name
Wd ress(if different from location)
City/Town State Zip Code
Telephone
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component: 0 Cesspool(s( Ef'Septic Tank M Tight Tank E] Grease Trap
El Other(describe):
4. Effluent Tee Filter present? F1 ( No If yes, was it cleaned? n Yes E] No
Y
5. Observed condition of component pumped:
6. System Pumped By,
Vehicle License Number
Company
7. Location where,contents were disposed:
--Zil
lgnWke o"Hau Date
....------
Signature' __of Receiving Facility(or attach facility receipt) .Date
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