HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 32 BRIDGES LANE 4/14/2025 Commonwealth of Massach(,isetts Town of%rth Andover
City/Town of
APR 8 2025
S System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health Other forrns, mayeJ?qll Mient-,
information must be substantially the same is that provided here. 9efore using lhis form, checl< will) yeti(
local Board of Health to determine the form they use 'The System Purnping 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 16 351.
HOUSE: fror<j]a � side rear le I�h
A. Facility Information BUILDING i front back side rear left rifnt
Important:When DECK: under
filling out forrns 1. System Location:
on the cornpulef,
use only the tab
key to MOVe YOW Address
cursor-do notes
MA
use the return
key Z.#r 1"W'-'n
2. Systern Owner:
Name
G1-ZJ1'1 NIQ
Address(If different from location)
MA
CRy(Town Slate ?ip Code
CIVL1
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
(5
3, Component: ❑ Cesspool(s) Septic Tank ❑ 'Tight Tank ❑ Grease Trap
[J- Other (describe):
4, Effluent Tee Filter present? EJ Yes No If yes, was it cleaned? E-1 Yes D No
5. Observed condition of component pumped,
6, System Pumped By:
Dave TIney Mass s 1 XA:A 9`5 Mass 1AD31Z
Name ehicle License N Aber
Gafeson Enter rises, Inc.
Company
7, a ion where contents were disposed,
G L - 0 -------------
�
----------- -------------
8iqnalure of Hauler Date
Signal RecelvIng'Facility (or attach facility receipt) Date
l5form4.doc, 11/12 Systern Pumping Record Paq(,,, 1 of 1