HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 88 SAW MILL ROAD 10/7/2025 Commonwealth of Massachusetts TOWn Of Noi`1h AndoVer
City/Town of
OCT 7 2025
System Pumping Record
Form 4
f4e'llh DepartM
DEP has provided this form for use by local Boards of Health. Other forms may be used, but theent
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 CIVIR 15.351.
HOUSE: <r�oni b)ick side rear left(�rig
t
A. Facility Information BUILDING: .o-nit' back side rear left r'i gz h"'
DECK: under
Important:When
filling out forms 1. System Loc2fi
c�:
on the computer,
use only the tab 'Address
key to move your
cursor-do not MA
use the return
key. City/Town State Zip Code
2. Sy rtm 7ner:
Address(if different from location)
MA
CityrTown State Zip Codq'—
-__le_ Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped.
Gallons
3. Component: ❑ Cesspool(s) [?,,teptic Tank 7 Tight Tank 7 Grease Trap
E] Other (describe):
4, Effluent Tee Filter present? [ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of compon?n pumped.'
6, Sys m Pymped By:
Da e Tiney Mass 1AA95E —Mass LlAD �14
Na a Vehicle License Number
B�teson Enterprises, Inc.
Company
7. L ation where contents vvq,�e disposed:
LSD
Signature of Hauler
Signature of Receiving Facility(or attach faality receipt) Date
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