HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 90 SPRING HILL ROAD 3/11/2026 TOW
) P,f Nofth Andover
Commonwealth of Massachusetts
Eg
City/Town ofMAR 16 2026
System P y umping Record
�
Form 4 ka _ a t-1
ent
DEC' 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,
E-i cU U S E•. front a c k"�s i d e rear, eft i t?h t
A. Facility information BUILDING: front back side rear left right
Important: When CHECK: under"
tilling out forms 1. System Location:
on fide computer, 0
use only the tab P` 'era ✓ �f �r �
key to move:your Address _
cursor-do notes MA
usethe return — _T_—�____ _._.------._._._._--------------......._._.----------
Cityffown State -._..- --- -----
key. � - Zip Code
f114_E11=1 2, System Owner'.
1{ N a m e ---- - -------
Address (if different fron7 location)
MR
City�hown 3f ale Zip Code
B. Pumping Record
'_ _._ ___
1. Date of Pumping ----- 2
Uale Quantity Pumped: ---- ----.__.
Gallons
31 Component: ❑ Cesspool(s) ] Septic Tank ❑ Tight Tank
g ❑ Grease Trap
❑ Other (describe)
4. Effluent Tee Filter presen/ponent
Yes ❑ Nc If yes, was it cleaned? Yes (� No
5. Observed condition of co pumped:
6. System Pumped By:
Dave Tlney_-- - .. . . ..-__ _ Mass 1AA95F_ Blass 1AD31Z
Name Vehlcic License Nt n e
Bateson Enterprises, Inc
Company
7, -1 1on where contents were disposed:
GLS
Si gnat o tauter Dafe
Signature of ReceivVng Facility (or afiach faci{ity receipt) Date -- --
t5form4.doc• 11f12 Systern Pumping Record Page 1 of'1