HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 325 SUMMER STREET 11/14/2025 Commonwealth of Massachusetts Town of NOrth Andever
City/Town of NOV 14 2025
System Pumping Record
Form 4 Health DepartMent
DEP has provided this form for use by local 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
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 15.351.
HOUSE: fro back side rea )r ght
A. Facility Information BUILDING: front back side rear-Te--f-t" right
DECK: under
Important:When
filling out forms 1. System Location,
on the computer,
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use only the tab —J ----------- ------
key to move your -;�ad ress
cursor-do not MA
use the return
key. CityfTown State Zip Code
2. System n e r
��^��� Name
reran t
Address (if different from�d�atit-o—n)
MA
'City/Town- State Zip Code
one Telephmberer
B. Pumping Record
1. Date of PumpingGallons
D�-t67-- 2. Quantity Pumped:
3. Component: ❑ Cesspool(s) Peptic Tank 7 Tight Tank ❑ Grease Trap
F-1 Other (describe):
4. Effluent Tee Filter present? 7 Yes [1,,,No If yes, was it cleaned? ❑ Yes 7 No
5. Observed condition of component pumped:
6, stem Pumped By:
Dq�a�Tlne
Tj
Dave Mass 1AA95E ass 1 AD3 i z
_
Name Vehicle License Numbe
on Enter prises, Inc.
Company
7. L tion where contents�yvere disposed:
.SD
Signature of Hauler
Signature of Receiving Facility(or attach facility receipt) Date
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