HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 103 FULLER ROAD 7/10/2026 Taw of North Andover
1-\ Commonwealth of Massachusetts
City/Town of JUL 15 2026
System Pumping Rec r
❑Y❑ , u 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. - ---------- rid- ----
HOUSE: fro t back side rear IefC right
A. Faculty Information - ' BUILDING: back side rear left t
Important:When DECK; under
filling out forms 1. System Location:
on the computer,
use only the tab 1
key to move your Address -- -
cursor-do not —_- MA _
use the return - - -___ _-._.-- ---- ._-----_.
key. City/Town State Zip Code
2. S ste Owner:
Name
"Ell
]-�12111��
Address(if different from location)
MA
City(Town -----_�-___-.------_.___-_- State Zip Code-- .v_-___._.
Tele hone Number -- ----- ---_._._
B, Pumping Record
77
1. Date of Pumping Date ------ 2. Quantity Pumped: Gallons --- -
3. Component: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4, Effluent Tee Filter present? ❑ Yes &"" o If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
----------- .__._.-- -- - --- -- _ ------------ _— __---------
6. ste Pumped By:
Dave Tiney - - Mass 1AA95E Mass 1AD31Z
Name Vehicle License Number
Bateson Enterprises, Inc. _
pany -
7. ocation w re disposed:
GLSD
6i❑nature of Hauler -�-------��-�-�__- -Date --� -----___
Signature of Receiving Facility(or attach facility receipt) Date
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