HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 42 BANNAN DRIVE 7/8/2026 Commonwealth of Massachusetts Town of NoO Andover
City/Town of
System Pumping Record JUL 15 2026
Form 4
0 rtment
orq1th Dpp'ns s
DEP has provided this form for use by local Boards of Health. Other may be sed, 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 CIVIR 15.351. right
HOUSE: fro ack side rear ft
A. Facility Information BUILDING: rant back side rear left:
DECK: under
Important;When
filling out forms I. System Lolc -,on:
C
on the computer, A via
use only the tab
key to move your Address
cursor-do not MA
AJ
use the return
key. CityfTown State Zip Code
2. System Own(t:
N AtKe
Address(if different from-1cZWion)
MA
Cityrrown —___._..__ ate --- zip Code❑_._____ _ __
elephone Number
B. Pumping Record
- 0 2 Quantity Pumped,
1. Date of Pumping -6ate a -Gallons
3. Component: 7 Cesspool(s) eptiC Tank ❑ Tight Tank F1 Grease Trap
F-1 Other(describe):
4. Effluent Tee Filter present? ❑ Yes.W,O'No If yes, was it cleaned? El Yes F1 No
5. Observed condition of compon nt umped:
6. yst'em PIA ped By:
Dave Tiney Mass 1 1AD31Z
ame Vehicle e ens Bateson Enterprises, Inc.
ompany
p
e�at is wier disposed;
7. ovation vvher, t s�were disposed:
LSS
D
Signature of Hauler Date
Signature of R c 1 Ing'Facility(or attach facility—receipt] Date
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