HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 147 JOHNNY CAKE STREET 7/2/2026 Commonwealth of Massachusetts Town of North Andover
City/Town of
JUL -6 2026
I 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 CM R 15.351
HOUSE: fr�back lef i it
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. System Location:
on the computer, 0
use only the tab
—0
key to move your Address
cursor-do not
fj A 0 MA
use the return
key. City[Town State Zip Code
2. System wner:
rah
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1Name
Address(if different from location)
MA
Cityrrown StatZip ad
7 le 'L�
Telephone Number
B. Pumping Record
1. Date of Pumping 2.11,Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) %Dteptic Tank M Tight Tank M Grease Trap
F-1 Other(describe):
4. Effluent Tee Filter present? R Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of comp ni pumped:
6. -_—S�—y stem
P
Dave Tiny1
4,Fnped By:
Mass 1AA95F M ass 1AD31Z
Name Vehicle LicensCmber
ruses,
7./11.--"'ati t@nt ,were disposed:
-oc 'on whir n
GLSD
C.
Signature of HauIa r Date
Signature of ke-�r—,eivingrFacility(or attach facility—receipt) Date
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