HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 192 STONECLEAVE ROAD 7/10/2026 Town of North Andover
=� Commonwealth of Massachusetts
City/Town of JUL 15 2026
y System Pumping Record
-= 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, clhecK 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.
Leh fight
HOUSE. — front Pack)side
side rea
A. Facility Information BUILDING: front rear right
Important: When DECK: Linder
filling out forms 1• System C_ cat*l
on the computer,
use only the tab
key to move your Address
cursor-do nut MA
use the, return --- __-_ { ...__ _ ..._. _.__. ______._ __,_--�-_--
key. City/Town State Zip Code
2. Sy m,Owner
-- Name
----_------ -
- -��`- address(if different from location)
MA
City/Town States, ode
Telephone Number
---._._ Te
._.___. _._ _ .--- �._._._. _—....___ .__----- Te —__ _.._..._-
B. Pumping Record
1. Date of Pumping —_' _. _.___.__.._.._-- _ 2. Quantity Pumped:
Datr, Gallons
3. Component: ❑ Cesspool(s) � S tic -rank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes ) N If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of corn on nt purnped:
Z424 4
rName
Pumped By:
Mass 1AA95E Ya
ss 1AD31Z
Vehicle License Num r
- terprises, Inc.
7. o where contents were disposed:
q>L§S,D
Signature of Hauler bate -- -
- --- --- ------— - --e -------
Signature of Receiving Facility{qr attach facility receipt} C7at
t5form4.doc• 11112 System Bumping Record •Page 1 of 1