HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 370 FOREST STREET 10/7/2025 Commonwealth of Mass'achusetts Town Of North AndOVer
City/Town of
System Pumping Record OCT 7 2025
Form 4
DEP has provided this form for use by local Boards of Health. Other forms 'may be us6i;l,,but the
information must be substantially the same as that provided here. Before using this form, checl�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: front ""side N_r ht .
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 -----------
key to move your Address
cursor-do not MA
use the return
key. City[T own State Zip Code
2. System Owner:
-R ---qA1tC_
a M
wn ' '0
Address(if different from location)
MA
CityrTown St t Zip Code
"Lumber-;el to Zip
e
B. Pumping Record
1. Date of Pumping -bate 2. Quantity Pumped, Gallons
3. Component: Cesspool(s) [ ~ Septic Tank El Tight Tank 7 Grease Trap
❑ Other (describe):
4, Effluent Tee Filter present? 7 Yes 10 If yes, was it cleaned? ❑ Yes 0 No
5. Observed condition of component pump d:
6, System-Pumped By:
D e Tlne Mass 1AA95E Mass VCD�IZ
me
N Vehicle License Number
me
Bates4n.-Ent'6rPrises, Inc.
C6_rn_p,a`ny___
7, J�G�tion Vher� content' e�e..disposed:
S
Signature of Hauler Date
-Signature—of-Receiving-'F-a�iflty(or attach facility-receip-t) Date
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