HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 50 BROOKVIEW DRIVE 4/22/2025 Commonwealth of Massachusetts TOWn of North Andover
City/Town of
APR 2 8 2025
System Pumping Record
Form 4
Health Departmqt
DEP has provided this form for use by local Boards of Health. Other forms may be use ,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 .,he Limping date in
accordance with 310 C M R 15,351,
HOUSE: rear front o�ht back side re� 'i ight
ght
ro
A. Facility Information BUILDING: ront back side rear
rfiportant: When DECK: under
filing oul forms System c- tion
on lhe compul8r, xec)
use only the lab
key to move your dregs
cu(sot -do not
use the return
key chyFrown Slate Zip Code
Z. ern Owner.
Name
Address (if different from location)
MA
Clly�l own Stale
1p Code
Telephone Number
----------
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Cor-niponent [� Cesspool(s) 4f7�'Septic Tank ❑ Tight Tank ❑ Grease Trap
Other (describe): ---------
4. EfflUent Tee Filter present? 7- Yes No If yes, was it cleaned? ❑ Yes ❑ Na
5 Observed condition of component pumped:
---------- —-------
6, Systen-i Pumped By.
Dave Tiney Mass 1AA95E Mass 1AD31Z
Nar'ne vehicle License Number
Bateson Enterprises, Inc
company
7 Location where contents were dlsposedGLSD
--------------------------
gnature of Hauler Dale
Signature of Rec-elving'Fa6lity(or attach facility feceipt) Datr,
SySle M Pumping Record Page 1 o(l