HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 203 MILL ROAD 4/10/2026 Commonwealth of Massachusetts o n of Nofth Andover
�h R. a City/Town of APR 17 2026
System Pumping Record
Form 4 Health p�artm nt
Department
/
DEP has provided this form for use by local Boards of Health. Gather 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 sulDmitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351
A. Facility Information 3ul�DINr: (26�ntbackNC7USE : ae:i< side rear eft 5M
y side rear riPr,t
Important;When DECK: under
filling out forms 1, System Locatio
on the computer,
use only the tat) _
key to move your Adk --
cursor-do not MA
IJ S P_the return
key.
City(r•own Sfafe 7_ip Gode��
2. System Owner:
Name
/NtY1J r r v
_ Address (If different from location)
MA
Tit mown
Y S!�Ie Ilp ode
Telepho e rnber
B. Pumping Record
1. Date of Pumping �Y �_ _. _._-_-. 2, Quantity Pumped
Daley Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
Other (describe): -_-.__—__----.---.___�_._�,__----_..._
4, Effluent Tee Filter present? ❑ Yes (�j 40 If yes, was it cleaned? j Yes D No
5. Observed condition of um onentt p jrry
"o•�,
6. System Pumped By:
Dave TIney Mass 1AA95E Mass 1AD317_
Name Vehicle License Nua er—
�•�3�t�'S"on Enterprises, Inc.
Company
7. Lo ati wher P.F' :
vSignature of HaulerDate
Signature of F,ecewlnq Facility (or affac h facility recclpt) Date
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