HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 120 CRICKET LANE 10/7/2025 Commonwealth of Massachusetts
Town of North Andover
City/Town of
OCT 7 2025
System Pumping Record
Forrn 4
Health Department
DEP has provided this form for use by focal Boards of Health. Other forms rn ay be used, but the
information must be substantially the; same as that provided here, Before using this forrn, check with your
local Board of Health to deterrnine 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
t-t0USf.: front back side rear I f r
A. Facility information BUILDING: nt back side rear left rif;hr,
Important: When
DECK: under
filling cut forms 1. SystqjT1 t-oc' 0n.
on usele,cmputer,
anhothe lab �) r
Y ._. -" . _.._
key to rreove your Address
cursor-da not MA
use the return
key, cityrrown e Zip Cade
2. Syste wner:
Name
lMLYII` 2
Address of different from location)
MA
City/7own 47late Zip Code
7slephone Number
B. Pumping Record
4
1. Date of Pumping ____ _._ 2 Quantity Pumped --.____
Date; �a'u3 I0n5
3. Component: Cesspool(s) septic Tank ❑ Tight Tank ❑ Grease Trap
Cw7 Other (descrlbe):
4. Effluent Tee filter present? ❑ Yes (-. No if yes, was it cleaned? Yes No
5. Observed condition of cornponent p mpe�� 6
6. Sy 1')un)ped By
Dave Tin' Mass 1AA95 Mass 1AD31Z
Name Vehicle License umber
ateso E::nterprises, Inc.
cry any
7 cifit 1er� - , s weiri .pTMc sad:
Signature of Hauler Date
Signature of h2eceiving f acuity(or attach facility receipt) Date ------ - _ __
t5forrr74.doc- 11112 System Purnf,7ing Record " f'age 1 of 1