HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 145 CRICKET LANE 10/7/2025 Commonwealth of Massachusetts Town of North Andover
City/Town of
OCT 7 25
System Pumping Record 2o
Form 4
Health DepaVe,,t
DEP has provided this form for use by local Boards of Health. Other forms may be used, bu
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 15351.
HOUSE:
—fr2o n back side rear Ift rich�
A. Facility Information BUILDING: front back side rear
Important:When DECK: under
filling out forms 1. System Location:
on the computer,
use only the tab
—011
key to move your Address
cursor-do not MA
use the return ---d-ow- -------
key, City[Town State Zip Code
2. System Owner:
"am e 41 L
Address(if different from location)
MA
Ity,701,w State i! ode
-Telephone Number
B. Pumping Record7
1. Date of Pumping QuaDate pntity uantity Pumped: Gallons
3. Component: ❑ Cesspool(s) �eptic Tank D Tight Tank ❑ Grease Trap
❑ Other(describe): .........
4, Effluent Tee Filter present?,-�'"'Ye s`jD1tq,6` If yes, was it cleaned? No
5. Observed condition of component pumped'.
6. System Pumped By:
,a �T-1 e Mass 1AA95E Ma4 1 AD3'1;�,
Vehicle License Number
B.1 teson E n rises,r �c...
Company
7, L cation where contents iWere-`N's posed:
G SD
Signature ofHauler Date
Signature of ReceivingFacility(or attach facility receipt) Date
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