HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 151 CARLTON LANE 3/30/2026 _ own of Nosh Andover
Commonwealth of Massachusetts
City/Town of
w .�_ _ APR 1
3 2026
System PumpingRecord
` Form 4
SY
f[St a Health [1--ePartment
D1=P has provided this form for use by local Boards of Health, other forms may be used, but the
inforMation must be substantially the sarne as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System PLImping Record must be submitted to
the local Board of Health or other approving @Llthority within 14 days from the p«mping date in
accordance with 31❑ CMR 15.351. -- - 7i �
HOUSE: front0ck side rear le r
A. Facility Information BUILDING: font back side rear left right
Iriiportant:when DECK: under
(filing out forms 1, System Location:
on the computer, !
use only the tab Jli 1
ley to move your Address r T
cursor-do not =
MA
A/
fee the return CitylTown ~-- Slate zip Code
y
2. S tem Qper:
Name
�ersrR ,t'
r
Address (If different from location) _ ----- -
MA
Cltyf'own -- Slate =�
ip de c
7-
Telephone dumber
B. Pumping Record
rC
1. Date of PLImping 2Dale ---� 2. Quantity Pumped: -j
Lallans
3, Component: [] Cesspooi(s) El �Pcic Tank E] Tight Tank g [� Grease Trap
❑ Other (describe);
4. Effluent Tee Filter present?' ❑ Yes �No If yes, was it cleaned? ❑ Yes ❑ No
5, observed condition of component purir)ped:
6, S em Pump By:
[have Tlney _Mass 1 AA9S Mass 1 AD3- 7
Name r Vehicle License Numb `W
F
B_ateSon Enterprises, Inc.
Company
7, ocation wh re co were lspo5etd:
(;
LSD
Signature of Hatiler Date
Signature of Receiving'Facility(or attach facility receipt) Date --
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