HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 10 PURITAN AVENUE 10/16/2025 Commonwealth of Massachusetts Town of North Andover
City/Town of
System Pumping Record
OCT 16 2025
Form 4
DEP has provided this form for use by local Boards of Health. Other fol-4' 4eQ0Pajtf"ent
information must be substantially the same as that provided here. Before using this form, 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 CIVIR 15.351.
HOUSE: front side side C-r--� r li�I f�tr righter
A. Facility Information BUILDING: front back side rear I ft right
DECK: under
Important:When
filling out forms 1. System Locata' n:
on the computer, `99d
use only the tab
key to move your Address
cursor-do not .-MA
use the, return
key. City/Town State Zip Code
2. S 7ym, nor,
Tcd--re-s-s--(Idifferent—-'-f-ro--ml o--c-at-i-o-n)
MA
City(1 own State Zip Code
7elephane Number
B. Pumping Record
1, Date of Pumping _D- 2. Quantity Pumped: -Gaiions
3. Component: ❑ Cesspool(s) F±�eptic Tank 7 Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? D Yes 0 If yes, was it cleaned? ❑ Yes E] No
5, Observed condition of component IN Fyr-nped*
A
6. System Pumped By:
Dave I In Mass 1AA95E Mass 1AD'�'!ilZ
I F
Vehicle License Nur b2r
139teson Enterprises, Inc.
Company
7. Location where contents were disposed:
GILSID
Signature of Hauler -Date
Signature of Receiving--Facility- attach facility receipt) Date
t5form4.doc- 11/12 System Pumping Record -Page 1 of 1