HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 45 CRICKET LANE 5/28/2026 Commonwealth of Massachusetts
ov�n ofNort
Andover
City/Town of
System Pumping Record MAY
Form 4 9 2026
DEP has provided this form for use by local Boards of Health, Ot"Oaf uI )e
Information must be substantially the same as that provided hero. Before using k 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 atrthority within 14 days from -.he pumping date in
accordance with 310 C M R 15.351 --- ---.___-----_----..--___—._----..-----____ —
HOUSE:
A Facility Information BUILDING: front back side rear left 1 t�
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Important:when DECK: under
filling oul forms 1. Systern Location
(M the computer, / %
use only the tab — � w__ � _ ____
key Io move your Address
cursor -do no( ( MA
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use the return
Cilrown _._ _ -0 ---
key. S(aie Zip Code
2 Syste �Owner; �
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Address (if different from loca(lon)
MA
Lip Code
Te ephone t urnber
B. Pumping Record
1. Date of Purnping Date - ---- - -- 2. Quantity Pumped
3. Cornponcnt: ❑ Cesspool(s) (] Septic "lank ❑ Tight Tank ❑ Grease Trap
Other (describe): -- ---._..__ --__._--
4, Effluent Tee filter present? ❑ Yes ( !o If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of cornpone t purrr��ed
(Dave
m Pumped By;
rineY, __._... _-_ _Mass '1AA95E: Mass 1AD31Z
- ' —Vehicle License Num
Waleson Enterprises_ Inc._
Company
7. Location wrni co •tc is were disposed
S D
nature of Hauler D ale
SIClndlur[, of Receiving (=r+Cllgy ((.)r aUaclr f;ir;ilrty receipt) .[Dale __....
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