HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 150 BRADFORD STREET 10/29/2025 Town of/UVVUy/ North Andover
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System Pumping Record
Form 4 He alth Department
DEP has provided this form for use by |ooe| Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
\OCa| Board of Health to determine the form they use. The System Pumping Record must be submitted to
the |000| Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15351 -----
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HOUSE: back side rea�_�i �
) r��ht
A. Facility Information 8U|LD\NG: front back side rear left right
DECK: under
Important:When
filling out forms 1. System Lonation�
on the computer,
use only the tab
key mmove you, *uureaa
cursor-do not
MA
use the return
key. City/Town State —' --'
2. System Owner:
Name
Address(if different from location)
MA
CityrTo=n State Zip Code
Telephone Number - ����-----���--
B. Pumping Record
1, Date of Pumping 2. Quantity Pumped:
Date Gallons
3, Component: Cesspool(s) Septic Tank Tight Tank Grease Trap
/
0 Other (describe):
4. Effluent Tee Filter present? 7 Yes No If yes, was it cleaned? Yes 0 No
5. Observed condition of componentpumped:
G. System pWmped By:
Dave T|ne Mass 1AA05E Mass 1AD3i2,
NLJM&(-,.r--
Bateson Enterprises, Inc.
7, L ation here contents were disposed:
t5fonn4dmc- 11/12 System Pumping Record 'roqa 1 of
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