HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 1030 FOREST STREET 10/16/2025 Town of Nofth Andover
Commonwealth of Massachusetts
City/Town of OCT 16 2025
System Pumping Record
Form 4 Haith 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 CIVIR 15,351.
HOUSE: r 7 nt P
(I '-" kk side re'b fight
A. Facility Information BUILDING: "frd'6i' back side rear left right
DECK: under
Important;When
filling out forms 1. System Location.
on the computer, 1 .
use only the tab I (-.,
key to move your Address
cursor-do not MA
use the return
key. City/Town Zip Code
2. System Owner:
/V
Name
Address(if different from location)
MA
CltyfrownState Zip Code
Telephone Number
B. Pumping Record
1, Date of Pumping 2, Quantity Pumped:
DateGallons
3, Component: ❑ Cesspool(s) L; �Septic Tank 7 Tight Tank ❑ Grease Trap
E] Other (describe):
4. Effluent Tee Filter present? 7 Yes 0 If yes, was it cleaned? ❑ Yes E] No
5. Observed condition of component pumped:
6. System Pumped By:
_gave Mass 1AA95E liass 1AD31Z
Name Vehicle License Numbe rL,
Bates -Enterprises, Inc.
e'i5ar—ny�--
7. Location where contents were disposed:
-G L S D.-"--
'3
Signature of Hauler Date
Signature ofReceiving--Facility(or attach facility receipt) Date
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