HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 94 WINDKIST FARM ROAD 10/16/2025 Commonwealth of Massachusetts Touun of North Andover
City/Town of
System Pumping Record OCT
Form 4
J4�
DEP has provided this farm for use by local Boards of Health. Oth � ,fnrG'm.* ; jgVj:bgtt e
information must be substantially the same as that provided here. Before using t is farm, cfie' 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 Ck
(s.d* rear lerl
A. Facility Information BUILDING: front side rear left right
DECK: under
Important:When
f8 the computer, af n
:
flYlm out forms
1. System OC
use only the tab
key to move your Address
cursor-do not MA
use the return ----.__ _______ �__ ~ � td � `__.__��__------ ___ _-
Key,
CityCTown State Zip Code
2. System Owner:
Narne
� 4
rvu�n f (I
Address(If different from locatipn)
MA
City/Town State r Zip Code
}
Telephone Number
B. Pumping Record
1. Date of Pumping _..___ _._....._. »_._.___ 2. Quantity Pumped.
Date Gallons
3. Component: (❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
Other (describe); _____-____.._----_-___.._._---------_.__._____--_---_.__________..___..- ---.___._._.._--------
4. Effluent Tee Filter present? ❑ Yes 'Na If yes, was it cleaned? ❑ Yes [—] No
5, Observed condition of compon nt pumped:
6. System Pumped By:
_Dave Tine-y_ �__-.___ _ _...__---__-- Mass 1AA95E Mass 1AD31Z
Name Vehicle license Number
Bat n Enterprises Inc. .
mpany
T. Location where contents were disposed:
GLSD
Signature of Hauler Date �_.--
__.....-__— ____.__....._._.__ __.__.._.__._.._-._..._-_—___-.._-------. ------.__---.__.._-.._._......__________-.-..___._��.__.___.-_.----._--_
Signature of Reeelving�Facility{or attach}facolity receipt) Date
t5form4.doc• 11/12 System Pumping Record •Page 1 of 1