HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 265 SUMMER STREET 7/8/2026 Town own of Noh Andover
`L\ Commonwealth of Massachusetts
Q2 City/Town of JUL 15 2026
System Pumping Record
;❑=-may,w` 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 CIVIR 15.351.
HOUSE: back side rear left rig
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A. Facility Information —BUILDING-:-en back side rear left(rvlt
Important:When DECK: under
filling out forms 1. System Location:
on the computer, IM
use only the tab ✓ -------
key to move your A;d dress
cursor-do not
MA
use the return
key. City/Town State Zip Code
2. System OwnD '
._ .0
rn Name
----------
Address(if different from location)
MA
CitylTown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: 7 Cesspool(s) 6ptic Tank 7 Tight Tank 7 Grease Trap
Fj Other(describe):
4, Effluent Tee Filter present? F-1 Yes ['I No If yes, was it cleaned? ❑ Yes D No
5. Observed condition of comp�4en pumped:o'
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6, S e-�N.mpecl By:
D e in Mass 1AA95E ��s 1AD31Z
—Name""
Vehicle License Number
Bateson Enterprises, Inc.
Company
7. Location where contents were disposed:
Signature of Hauler Date
Signature of Receiving Facility{or-attach facility receipt) C7ate
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