HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 142 DUNCAN DRIVE 4/22/2025 ConTonwealth of Massachusetts TO" OfI North Andover
City/Town of System Pumping Record APR 28 2025
Form 4
DEP has provided this forn-i for use by local Boards of Health, QMPF91144 DepartMfte
Information must be substantially the same as that provided here. Before using this form, k with your
local Board of Health to determine the form (hey use, The System Purnping Record must be submitted to
the local Board of Health or other approving authority within 14 days from -.he pumping date in
accordance with 310 OMR 15.35'1
HOUSE: -------
eft right
side rear
' 'e 'A. Facility Information BUILDING; front back-�ce rear left right
Important; When DECK: under
Milling out t0rMS 1. y`stern Lcc tion:
on the computer,
Use only(no lab
—---------
key to move your Ad res
cursor -do not 44_014t-�" MA
use the return
key Chy/Town I P"-r.�e_
2, Skstern Owner:
Address (it different from ocaiion)
MA
ti'�fovyn --------- a e
_PCode
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped'.
Da eGallons
3. Component, ❑ Cesspool(s) �eptic Tank ❑ Tight Tank El Grease Trap
0(her (describe): ------ -------
4. Effluent Tee Filter present? [] Yes �.��o If yes, was it cleaned? E) Yes [] No
5. Observed condition of component burnped:
6 System Purnped By
_Dave_Ti_n e,y" MasslAA95E Mass IAD31Z
Vame Vehicle License Number
BaIeson Enterprises, Inc
7, Location where contents were disposed�
G L5 D ----------
......----------
Signa(ure o rlauie l.)a(e
Signature of �,eceiving Facility (or attach_f_acT14yr_eceiV_)_ Date
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