HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 250 FARNUM STREET 7/14/2026 Town of Not Andover
Commonwealth of Massachusetts
City/Town of JUL 15 2026
x -- System Pumping Record
a 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 CMR 15.351. HOUSE: front ack side rea left�ht
y µ^ -
_._.___________ __ __ ._.,.._ _._
A. Facility Information BUILDING: l� n' back side rear left right
DECK: under
Important:When
filling out forms 1. S1�n-
keym Locati
r�,
on the computer,
use only the tab ._.__
to move your As
cursor-do not MA
use the return Cityrrovun State Zip Code --~
key.
y 2. System Owryer:
- r
Name
Address(if different from location)
MA
Gity(Town ip-Cede_._,...__._._.________._..
_
Telephone Number
B. Pumping Record
1, Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑] Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease-Trap
❑ Other(describe):
4. Effluent Tee Filter present? ELY No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of compo nt umped:
6. Syst Pumped By:
Dave Tines Mass 1AA95E ass 1AD31Z
Name Vehigle License Numb ,
Bateson Enterprises, Inc.
Company
7. Location v�ber ntents w e- gsed:
GLSD
Signature of Hauler Date
Signature of Receiving Facility or attach facility receipt) Date
t5form4.dac• 11/12 System Pumping Record-Page 1 of 1