HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 311 DALE STREET 6/8/2026 Commonwealth of Massachusetts Town of NOfth Andover
City/Town of
J 1
System Pumping Record UN 50
Form 4
Health Dee,�VWOW
DEP has provided this form for use by local Boards of Health. Other forms may be
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 CIVIR 15.351. --------
HOUSE: ro back side rear left(rii*g�ht
A. Facility Information BUILDING: front back side rear left rig-h-C-
DECK: under
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab ------ -------
key to move your Address
cursor-do not
use the return
key. City/Town State Zip Code
2. System Own
V1 -------
,r, Name
.Address(if different from location)
MA
City- own State Zip Code
Telephone Number
B. Pumping Record
C'
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) eptic Tank F-1 Tight Tank ❑ Grease Trap
F-1 Other(describe): ------
4. Effluent Tee Filter present? F-1 Yes ff/No If yes, was it cleaned? ❑ Yes n No
5. Observed condition of compton pumped:
6. Sy tem
�-�— . q rnpecl By:
ve TiR y Mass 1AA9 ss 1AD31Z
�a :
Vehicle LicenseNumber
m
Bateson" Enterprises, Inc. ......
Company
7. Location where contents were disposed:
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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