HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 42 CROSSBOW LANE 10/7/2025 4 Commonwealth of Massachusetts Town °f North 4ndover
r City/Town ofOCT 7
= System Pumping Recordz5
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Farm 4
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DEP has provided this form for use by local Boards of Health. Other forms mayeGsd,41
information must be substantially the same as that provided here. Before using�� this form, check(th 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 back side e left Ight
A. Facility Information BUILDING: front back s rear e right
DECK: under
Important;When
Location:
filling o the tab
forms 1. System �
on the computer,
use only
key to move your Address
cursor-do not r MA
use the return ___—.___. _----- ..._
key. City/Town State Zip Code
2. SyspemOwner:FV[ , . .`
� Nam _..
A,tldross(ff different from Ioaation)�
MA
CityCrown State Zip Code
Telephone Number
B. Pumping Record
..............
1. Date of Pumping ------- _._._-.__._-.-- 2. Quantity Pumped;
Date GaI{ans
3. Component: ❑ Cesspool(s) L<Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes J No If yes, was it cleaned? ❑ Yes ❑ Na
5. Observed condition of component pumped,
s
6. Tm
tamped By:
e Mass 1AA95E Ma 1AD31Z
Vehicle License Number
Fz�terprises, Inc. '
Company
7. Location wt re nts_werisposd:
G SD
1 -
Signature of Hauler Date —
signature of Receiving Facility(or attach facility receipt) Date
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