HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 25 JERAD PLACE 11/14/2025 Commonwealth of Massachusetts Town of North Andover
G, s fi r Clty/7 Own of --_—
s _ System Pumping Record NOV 2 12025
Form 4
,} r
DEP has provided this form for use by local Boards of Health, tV it d 030at the
nformation must be substantially the sarne as that provided here. Before using this forrn, check with your
local Board of Health to determine the forrn they use The System Purnping 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 MR 15,351 --_-- �'"
HOUSE front„back side rear lefrif;
A. Facility inforrT atiof7 BUILDING. front back side rear left rigI
Important;When
DECK: under
filling out forms 1, Sy tern location
on lire computer,
use only the tab
key to move your Addres' _
r.ur of -do no(
use the return --- -.. ___ ._ . 1ft '.l� C .._._ MA
key Clly/Town slate Lip Code
2. Syst, wner: �-
/ k—��aC q.....
N a rn e --- -— --- -
rnrn
Address (it different (ram location)
MA
Clly/Town States lip Code
e- ph.' 3U ,ber
B, Pumping Record
1 Date of l urnping - -- _._ 2 Quantity f umped _..Gall.__.
Dale . ons
3. Component. ❑ Cesspool(s) Fc? Septic -Tank ❑ Tight Tank ❑ Grease Trap
Other (describe): —.---- ------------ - -- -- - —
4 Effluent Tee (inter present? L_] Yes ( No If yes, was it cleaned? ❑ Yes [] Na
5. Observed condition of component pt.trn/peed:
-v _ ------- ----- ---- _---
b. Sy -'ern Pumped By:
Dave Tin Mass 1AAOSE Mass 1A'1)31Z
-.. _..
anis 71
Vchu,lc LicenseNurnb�r,.
Bateson Enterprises, Inc.
C,ornrrany
E
7 L ca(ion
wine P�cant�nts were disposed --------------
Signalufe of Hauler Data
nalure of rte.Ccivind f=aCilily (or nl(raclr fer,ihly re;Ce;ipl) (Date
I5form4.duC 11112 Systern Pumping Record Page 1 of 1