HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 478 BOSTON STREET 10/7/2025 Commonwealth of Massachusetts Town of North Andovgr
City/Town of
System Pumping Record 11T _ 7 2025
Form 4
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DEP has provided this form for use by local Boards of Health. Other forms may e
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 acicleere) left('ri
ght
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer,
use only the tab 'A- 1� . i�
key to move your Address
cursor-do not ............ e _MA
use the return key. City[Town State Zip Code
d
2. S em Owner:
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Name
rcrwn
Address(if different from location)
MA
CitytTown State Zip Code
_fjG`p k-o-n-W Number
' _ -'-
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Datealigns
3. Component: ❑ Cesspool(s) 12-11Septic Tank 7 Tight Tank ❑ Grease Trap
[] Other (describe): —----------.......
4. Effluent Tee Filter present? 7 Yes eo If yes, was it cleaned? F Yes ❑ No
5. Observed condition of component p ped:
A
System Pumped By:
Dave TIney Z Mass 1AA95E Mas 1AD31�
Name 'Vehicle License Number
Bateson Enterprises, Inc.
7 Lo'at', here contents wer disposed:
GLSD
o�
Date
_ST_n_atu_re R-R-e—ceiving Facility—(or an—ach--fa—ci-l-it-y r_e__ce_j_pt)._-_______ Date
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