HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 190 GRAY STREET 9/5/2025 Commonwealth of Massachusetts Town ofN®rthAndover
(amity/Town of _
System Pumping Record SAP 55
Form 4
r`
DEP has provided this form for use by local Boards of Health. Oth r
information must be substantially the same as that provided here. Before using t s r 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 on back side rear left right
A. Facility Information BUILDING: front back side rear left right
Important;When
DECK: under
filling out farms 1. System La tlon:
on the computer,
use only the tab
s�
key to move your Address
cursor-do not Cit ITawn State Zit Code
use the return ----- MA.
key. Y p e_____.__..
r/ 1 2, System Owner: .-
__ __.
,. Name
rerwn�ff)
Address (if different from location)
MA
City/Town State p Cade
Telephone hJumber
B. Pumping Record
1, Date of Pumping __.._......__. ___ _ 2. quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) [3 Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): --- ___
4. Effluent Tee Filter present? & Yes [-,] No If yes, was it cleaned? Yes ❑ No
5. Observed condition of component pumpep:
..,...
6. Syst mPumped By:
____. _ --___.__ ._.._.._ _..._..__.- ____-- — ------.._.. _ ,
Dav Tlney-_ __ Mass 1AA95E Mass 1AD31�
Nam Vehicle License Number
Bateson Lnterprises Inc
Company
)'
7 LSDon whec contents ere isposed:vo� .Win, ��M.._
Signature of Hauler _-`__ -Date
Signature of Receiving Facility(or attach facility receipt) Date
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