HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 105 CARLTON LANE 4/10/2025 Commonwealth of Massachusetts Town of'JOrth 4ndover
City/Town of
P ] f
System Pumping Record APR 2025
Form 4 Hearth P, -
DEP has provided this form for use by local Boards of Health. Other forms may 5 ,jqi(l) YOL�r
information must be substantially the same as that provided here. Before using this form, chec
local Board of Health to determine the form they use. The System Pumping Record must be submitted lo
the local Board of Health or other approving authority within 14 days from the Pumping date in
accordance with 310 C M R 15,351.
HOUSE: front (aa-ck)side rear Le6'righz
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
key to move youf Address
cursor-do not ,N— MA 0
use the return w� ---
key, Tlt7/ own
wn State Zip Code
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2. Sy� m 0
10/ ILI yvner
lei
Address (If different from location)
MA
CIty/Town Slate
4 - Zip Code
_Q -
-Telephone Number
B, Pumping Record
1, Date of Pumping 2. Quantity Pumped 15�
DateGallons— -,--- -,
3. Component: cesspool(s) Septic Tank Tight Tank ❑ Grease Trap
0 Other (describe): --------------
4, Effluent Tee Filter present? ❑ Yes ] No If yes, was it cleaned? Yes [] No
5, Observed condition of component purnped
6. System Pt�mped By,
.Dave Iney "I' M ss 1AA95E-' Mass 1A031Z
Name �iohlcle 1-icense W ber
Paiesqn Enterprises, Inc -------
Company
7, lion where contents were disposed
-Slgnai�-re of Hauler Dale
Signature ofR c lvingTacilit r attach facility receipt) Date
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