HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 340 FOREST STREET 4/13/2026 Commonwealth of Mass-achUsettS wI"1 of North Andover
x ra City/Town of APR 17 2026
System Pumping Record
Form 4
�Health DepartMent
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 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 C M R 15.351. -----------__.�rr-o.
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__.___�_—� MOUSE: nt back side rear left right
A. Facility Information BUILDING: ont back side rear left rigt,t
Important: When DECK: under
filling out forms 1. System Location:
on the computer,
use only the tab
key to move your Address
cursor-do not s �p
use the return — `. ----- ------ `_ _. ----- M A — s..- -`g -
key. City/Town State Zip Code
?_. System Owner:
me
ee7ron
Address (if different from location) —
MA
Cif (Town
Y Stale Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping -_._._.---_--.__-__ 2 Quantity Pumped:
Dale Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ 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 pumped:
.�
6. System Pumped By:
DaveTlney Mass 1 5 Mass 1AD31Z_
Name Vehicle, License amber
Bateson Enterprises, Inc.
Company
7. Location where contents were disposed:
n
_-_.. -
_ �/
Signa r Hauler Date
— ------------------- --_.._. -----
-
Signature of Receiving Facility(or attach facility receipt) Date --- - ---
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