HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 189 CARLTON LANE 3/28/2025 Commonwealth of Massachusetts Town of North Andover
City/Town of
APR - 2 2025
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 CMR 15.351. ----
HOUSE: rant back side rear ClefSl right
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 -Xi
key to move your Address
cursor-do not VIA
use the return
key. Zity/Town State Zip Code
W/01�6 2. System Owner:
Name "_. __—__. � —❑--- � ---
Address (if different from location)
MA
City/7own State Zip Code
Telephone Number
B. Pumping Record
1 2 k,
1, Date of Pumping 2. Quantity Pumped'.
Date Gallons
3. Component: F7 Cesspool(s) Septic lank Tight Tank F7 Grease Trap
[] Other (describe):
4. Effluent Tee Filter present? 7 Yes No If yes, was it cleaned? ❑ Yes ❑ No
5, Observed condition of component pumped:
6, System Pumped By.
Dave TIney -1��ss `IAA9� Mass I AD31 Z
Na -�/ehlcle License ,umber
.Bateson Enter
Company
7. . tion where contents were disposed:
LSD
Signature of Hauler Date
Signature of Receivingattach Facihty-(or-att-e,---
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