HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 411 SUMMER STREET 11/14/2025 Commonwealth of Massachusetts Town of NOrthAndoVer
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City/Town of
a System Pumping Record NOV 14 225
Farm 4
DEB has provided this form for use by local Boards of Health. Other fo'r t th
Information must be substantially the saute as that provided here. Before using"this , with yaur
local Board of Health to determine the form they use. The System Bumping 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: front side rear left �ht
A. Facility Information BUILDING; front back side rear deft right
Important;When DECK: under
fltUng out forms 1. System Location:
on the computer,
use only the tab
key to move your Address
cursor-do not �,-� MA J 4)
use the return
key. Cityrrown State Zip Code
2. System Owner:
-- - . _ ...
Name
Address (if different from location)
MA
Cityr'own state Zip Cade
Telephone Number
B. Pumping Record
0
1. Date of Bumping ' ' -- - 2. Quantity Bumped _..�� �
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
[] Other (describe) --. -__-.-___, _ ___.--____ _.___.._ _.-__ -..-....-__.__-._-_-__
4. Effluent Tee Filter present? C] Yes No If yes, was it cleaned? (❑ Yes ❑ No
5. Observed condition of cornponent umped:
C. System Bumped By:
Dave TIneY_ .-. .._.__. .. . Mass 1 AAg5E ass 1 AD31 Z
Name Icle License Nur
Bateson Enterprises Inc.
Company
7. I_ 'on where contents were disposed:
GL.SD
/0J_2ejzv-
Signa �ew^s solar Date
Signature of rteaelving Facility(or attach facility receipt) Date
t5form4.doc- 11/12 System Pumping Record -page 1 of 1