HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 75 DUNCAN DRIVE 10/31/2025 - �._
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Commonwealth of K8��ss��C�hus��fts Town of North
City/Town
�'fx7 f Andover
ap �^|�y' /T[)VV|l of
���s��K� ��������~��� ������F� OCT � �?��System Pumping' �� Record— � � �,��
Form 4
He
DEP has provided this form for use by local Boards nfHealth. Other forms Q'�
IbOajqa
information must be substantially the same as that provided here. Before using this form, c�����ith your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health qr other approving authority within 14 days from the pumping date in
accordance with 31OCKAR 15.351
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1, System Location:
on the computer,
use only the tab
key to move your pmumn» _
cursor'do not MA
use the return
key. Cit—'fT—n State— --
Code
2. System Owner:
Name
Address(if different from location)
MA
State Zip Code
0 S-
-telephone Number
B. Pumping Record
1. Date of Pumping Date Gallons
3. Component: E] Cesspool(s) Septic Tank 7 Tight Tank Grease Trap
,
F] Other (describe):
4. Effluent Tee Filter present? 7 No If yes, was it cleaned? F� Yea [l No
5. Observed condition of component'Pumped:
6. System Pumped By:
Dave TlLey Mass 1AA95E ass 1AD314
Name venuue Lo°mm mvmvo, -------~
Bate Bateson Enterprises, Inc.
7. Location where contents were disposed:
-§i7g�ature of Hauler Date
t5fonn4.doo n/o System Pumping Record 'Page 1 of
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