HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 155 CHRISTIAN WAY 1/28/2026 Commonwealth of MaSSachUsetts Town of North Andover
City/Town of
a = = System Pumping Record JAN 2 8 2026
Form 4
r „, r
DEP has provided this form for use by local Boards of Health. Other forms may he us ,
information must be substantially the same as that provided here. Before using this form, check witpyour
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: ro`n ack side rear left rid t
A. Facility Information BUILDING: ront back side rear left right
Important: When DECK: under
(Illing out forms 1. System Location:
on the computer,
use only the tab .*e ,_tom✓ -------------
key to move your Address
cursor-do not
use the return —F=."-! -- ---_--__ _ _._.___ . ----__-_-- MA j
cit crown
key. y State Zip Code
r 2. System Owner:
ame
rerun
--------------
Address --
(if different from location)
MA
CityCrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping ---.—____._.._. _-- 2. Quantity Pumped,
-- ---------.--___-_-.
Dale Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tank Tight
g ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component purnped:
car w/
6. System Pumped By:
Dave Tlne� V----- - -----_-_.__-------_.____ ._ _ _Mass 1 AA9 _ Mass 1 AD31 Z _
Name Vehicle License N r-nber —'-- -
Bateson Enterprises, Inc.
Company
7. atian where contents were disposed:
(GLSD
gna uler Date
T— _____-. --_..._ _
Signature of Receiving Facility(or attach facility receipt) C7ate ------" "- -""
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