HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 132 CRICKET LANE 3/30/2026 Comnnonwealth of Massachusetts Tow" cl NOrth Andover
City/Town ofAPR 13 20
26 h � ystem Pumping Record
4 }., Form 4
He
DEP 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 you(
local Board of Health to determine the form ;hey use. The System Pumping Record rnust 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 �acV< side rear Ieft r �ht
..__.,.
A. Facility infart-nation 8 U ILDING: front hacc� side rear Ieft rigt)t
Important: Whon (BECK: under
Mling out forms use c the tat 1. Sy stern I ocntlon
or,fhe omputr:�r,
y .c ._
k;ey to move.your Addrem
cursor-do not fVA
use the return ___________...
c t rrowr, __ -.- -------
Key. Y State Zip Code
2, System Owner:
y_._, ___.___ _. ....._
loan
F,ddress (If difiereni Irom locatiorr)
MA
City(1'owrt Staate� a Lii ode
Telepd�one iWun)ber
B. Pumping Record
1 Date of Pumping C)atrs __...._ ____---- 2. Quantity Pumped. -�_
Gallons
3, Component: Cesspool(s) eptic -Tank (_-f Tight Tank ❑ Grease Trap
Other (describe):
4, Effluent Tee Filter resent?p T Yes � h�10 If yes, was it cleaned? [_] Yea No
5. Observed condition of corn onent purnpe ;
_.....
6. S stern �..,._
rO.Plamperi By:
D ve Tlneyt_._ Masi 1! A95 Mass 1F�C7311_
__.._._.
N me Vehlr.lr,, !._icc nse Nu ben
Ba Ewnkerprlse,s, Inc _....
company
7. b 'anon where contents were disposeo,
-------------
LS
Siynaturo of 4-tauler [7ratc
S6ynature of f er;r;ovlrul Facility(or arach facility rec,,eipl) Grate
f5forrn4.doc, '11112 Systern Pumping Record -page 1 of 1