HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 44 CRICKET LANE 6/30/2025 Commonwealth of Massachusetts Town of Norfh AndoVer
City/Town of
JUN 3 0 2025
System Pumping Record
Form 4
Health Dep
DEP has provided this form for use by local Boards of Health, Other forms may be u a,rdtrD
information must be substantially the s@rne as that provided here. Before using this form, check with your
local Board of Health to determine the forrn they use, The Systern Pumping Record must be submitted to
the local Board of Health or other approving aullhority within 14 days from -.he pumping date in
accordance with 310 CMR 15.351
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HOUSE: front ackcle e ' left t
A. Facility Informatiori BUiLDING: front back side rear left rig
Important:When DECK: under
(Ifflng out forms I Systern Location:
on II)e computer,
Use only the lab .-_�/
key to move your Address
cursor -do not I I
A-/_1 MA
use the return —.._.._—.—..._...______..—
key, Chyrrown Stale Zip Code
2, Svstern Owner
K" '
r
f arne
L-111 ZIR
Address (I(differar7l warn location)
MA
_,Y/To_wn State —Zip C_od(�I _c__________
ufnbe(
B. Pumping Record
f <
I. Date of Pumping 2 Quantity Pun-tped� )
DaieGallons
3. Component: cesspool(s) Septic<tl rank ❑ -right Tank ❑ Grease Trap
0 0(her (describe).
4. Effluent Tee Filter present? [_ �Yes No If yes, was it cleaned? -r-<Yes 0 No
5. Observed condition of con-iponenl, I umpec j C. Sys u n-i pe,d IBI y
ave 1-ine Mass IAA95E Mass IAD31Z
nlame Mass
Y
Vehicle Llcense t,}un ber
Enterprises,'' ) Iric.
company
7 ^yl )n where contents were disposed
L 5 D
Signature of Haute(
— ------
Signature of RecelvIng acility(or auact�r faciiit-y receipt) Dale
Syslern Pumping Record Par)e 1 of 1