HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 360 FOREST STREET 9/2/2025 Commonwealth of Massachusetts
Town of Nodh Andover
a City/Town of
System Pumping Record SEA 5 2025
xT Form 4
DEP has provided this form for use by local Boards of Health. hs the
information must be substantially the same as that provided here. Before using this orm,'c'lteck 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 the pumping date in
accordance with 310 CMR 15,351.
HOUSE: °f ack side rear left r ht
A. Facility Information BUILDING: front back side rear left right
Important:when DECK: under
filling out farms 1° System Location:
on the computer,
use only the tab
key to move your Address
cursor-do not r� � MA
use the return
Rey, CityCrown State Zip Code
2. Sy m Own r: t
___ .--__ _._ ---
(\ Name
Address(if different from location)
MA
CityrTown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping - _
E�- --- ---- 2. Quantity Pumped: 1l --..—_.._______,..__......-
Data Gallons
3. Component: ❑ Cesspool(s) ❑ .eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe);
4. Effluent Tee Filter present? ❑ Yes C No if yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By: _.._,.......-�
Dave Tiney - -- Mass 1AA95E _ ass 1AD31Z
___—.-__-_..-_ _ _
Name Vehicle License NurYibe
Bateson Enterprises, Inc. � ~---
Cor7ipany
7. Location where contents were disposed:
GLSD -
_Date
Signature of Receiving Facility(or attach facility receipt) Date - --
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