HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 50 STONECLEAVE ROAD 10/16/2025 Commonwealth of Massachusetts Town of NorthAndover
City/Town of
System Pumping Record OCT 2025
Farm 4
DEP has provided this form for use by local Boards of Health. Other forms rt�. )r;0 ,
information must be substantially the same as that provided here. Before using this form, erwr
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 C M R 15.351. ----.------- --.. --— - - __._
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HOUSE: fronta k side rear` le r
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. System 1,G�cation:
on the computer,
use only the tab . ---------- _._�
key to move your Add"o s
cursor-do not MA
use the return - Y- _. G.�- -J� __�__._ __.._.._ __.__ _C._____. __...__ -.--- -- _..-----------
key.
Cik CToWn State Zip Code
I#El 2. System Owner:
------------
Address(if different from location)
MA
C{tyf 0.Wrl State Zip Code
Telephone Number
B. Pumping Record
j
1. Date of Pumping ___ _ 2. Quantity Pumped.
pate Gallons
3, Component: ❑ Cesspool(s) L Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): __ ____ _..______._.__...__________-w_____-.__----------._______-._. ._-----__--_._..__-______._____..___.
4. Effluent Tee Filter present? ❑ Yes . No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of com anent pumped�
& System Pumped By:
Dave Tlney� Mass 1AA95E Mass 1AD31Z -.- -
Name Vehlcle License Number
Bateson E,,ter rises, Inc.
Cgrrrpa
7. Location where contents were disposed:
GLSD
--A —_. __ . ..____..___ ___. _. _._..... _.._. _.__...._.__.._-_ .._-----.______-_ _. ._._...
Signature of Hauler Date
_____._ _--_ _.__,._. _ ._._.. _.___ __—___- .-__._
Signature of Receiving Facility(or attach facility receipt) Date
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