HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 221 CAMPBELL ROAD 10/27/2025 Commonwealth of Massachusetts Town Of ivorth 4ndover
City/Town ofOCT
r
System Pumping Record 312025
<� Form 4Dpe
L
DEP has provided this form for use by local Boards of Health, Other forms may beuse" `nVC
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 -.he purnping date in
accordance with 310 C M R 15,351 ---.----_—_ __-- _ ~�—__-_- -----
HOUSE: ck side rear left
A FacilityinfOrma IOfI BUILDING: front back side rear leftQ,",'11
Important:When
DECK: under
fiiling out forms 1. System t_ocatlof
on the computer,
use only(he (ab --44—_�
key to move your Address
Cursor -do no( // MA
use the return -__ N---. _. 1.__. _.._ ___.._._ --_- -__--
key, CltylTown slate Zip Code
JhI
N m e
relcvn '
Address (if dif-ferent from Ioca(lon)
MA
State _ _.__ 2TP-
- a<t€
T J -
e e-ph cYn e Nurnber
B. Pumping Record
1. Date of Purnpinra ---_ _ .- fC __ _..._ 2 Quantity Pumped, (M -- -- -
Dale Gallons
3 Component. ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe), —---------- —..-- ..--------------------- _----_
4. Effluent Tee Filter present? ❑ Yes [7T No If yes, was it cleaned? ❑ Yes [] No
5. Observed condition of component,.pumpeysl:
6. System P r7-tped By
Mass IA�SE ass 1A031Z
\/CthiCIC License Nurnber
Bateson Enterprises, Inc.
Company
7- L cafio Where contents were disposed'
G 5 D
signature of Hauler __ Date,
_
Slgnalure of Fteceiving f s,cllily (or at(aoY, facility receipt) Date ----
t5iorm4.doc, I IM2 System Purnping Record - Page 1 of t