HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 56 CRICKET LANE 4/10/2025 Commonwealth of Massachusetts
Town of Nofth Andover
City/Town of
System Pumping Record
Form 4 APR 14 2025
DEP has provided this form for use by local Boards of Health mopo ? -,k with your
I tT
ifit the
nformation must be substantially the same as ffint provided h 0-,� 14 , t r ri ffec
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: front ac side rrea�rleft right
A. Facility Information BUILDING! front back side rear left right
Important:When DECK: under
filling out forms 1, Systern Location,
on the computer,
use only the tab
key to move your Address
cursor-do not
use the return MA
key, City own State —Zpg4d -
2. Syst m ow
Name
Address (If different from location)
MA
Slate Zip Code
Telephone Numraer
B. Pumping Record
1. Date of Pumping 2 Quantity Pumped Gallon
3, Component: ❑ CeSSPOO!(3) Septic Tank E-] Tight Tank [I Grease Trap
0 Other (describe), -------
4. Effluent Tee Filter present? Yes _] No If yes, was it cleaned? Yes [] No
5. Observed condition of c�mponent pumped,
6, System Pumped By,
_gave TIney ass 1 96�E-
so
Name License Mass 1AD31Z
eateson EnfeSrrises, Inc,
Company
7. tion where contents were disposed,
G L S
Signature of Hauler Dale
Signature of Receiving Facility(or attach facility receipt) Date
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