HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 20 NORTH CROSS ROAD 9/10/2025 Commonwealth of Mass.1 achusetts Town Of NO�h AndOVer
City/Town of
ym System Pumping Record SEP 19 2025
Form 4
DEP has provided this form for use by local Boards of Health. Rf but the
information must be substantially the same as that provided here. Before using this 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 the pumping date in
accordance with 310 CMR 15.351.
HOUSE: front back(s7et ea(lefi-fight
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab �Jt,-,,.ri-k
key to move your Address A
cursor-do not MA
use the return City/Town ptode
key.
2. System Owner:
Name
Address___. (if—different from lo—c—atio—n)
MA
City/Town State ,Zip C
Telephone
B. Pumping Record
1. Date of Pumping —----- -Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) ZI Septic Tank ❑ Tight Tank ❑ Grease Trap
Other(describe):
4. Effluent Tee Filter present? 7 Yes No If yes, was it cleaned? ❑ Yes E] No
5. Observed condition of compo e t,pumnpe
6. Sys m Pumped By:
D ve Tin MasslAA95E Mq�s 1AD31Z
m
t---
N me Vehicle License Number
ateso�Enterp i!je Inc.
y
7. cation where contents were disposed:
'z
l9nature of Hae(er
Signature Receiving Facility Date
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