HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 78 LACY STREET 10/16/2025 Town of North Andover
Commonwealth of Massachusetts OCT 16 2025
City/Town of
System Pumping Record
Form 4 Health Department
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
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 CMR 15.351. ------
HOUSE: front„ ht
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. S Ste Loc ion:
on the computer.
use only the tab
key to move your Address
cursor-do not MA
use the return City[Town State Zip Code
key,
2, SysteMOwner: I
( 1,44
6 ——---------
Name
_.__..—
Address(if different fromlocation)
MA
City(Town StaLte , de
-feTephone Number
B. Pumping Record
1. Date of Pumping -cTa—te - 2. Quantity Pumped: Ga
I 4,n s��
3. Component: 7 Cesspool(s) 29`eptic Tank ❑ Tight Tank 7 Grease Trap
0 Other (describe):
4. Effluent Tee Filter present? ❑ Yes P_116 If yes, was it cleaned? E] Yes 7 No
5. Observed condition of component pumped,
6, System Pumped By: ❑
Dave Tiney Mass 1AA95E Ma s 1 AD31Z
Name Vehicle Vehicle License Number
Batesan Enterprises, Inc.
7. Location where contents were disposed,_
GLS
Signature of Hauler Date
Signature o_fReceiving`Facility—(or attach--facility—receipt)—' Date
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