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HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 93 WINTERGREEN DRIVE 7/9/2026 Commonwealth of Massachusetts Town of North Andover _V City/Town of --- _- : System Pumping Record JUL 15 2026 Farm 4 'ems Health D artment DEP has provided this form for use by local Boards of Health. Other forms may be used, ut 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 back side rear ftight A. Facility information - BUILDING: front back side rear left right Important:When DECK.: under filling out forms 1. System Location: on the computer, use onlythe tab _ tol'ol ri _-- key to move your Address cursor-do not MA _ use the return City(Town — — -- State Zip Code Key. `�/1 ❑ 2. System © r: Name Address(if different from location) _ MA City/Town State -� ❑ _ Zip Co— Azk "I T epho ber B. Pumping Record Num 1. Date of Pumping Gate - --- 2. Quantity Pumped: Ga'Itvn s —__--- 3. Component: ❑ Cesspool(s) S Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): ___--— 4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of compone t pu ped: A. 6. System Pumped By: Dave Tiney— -- ------- -_- - - _ Mass 1AA95E Mass 1AD31Z�� - Name Vehicle License Number Bateson Ente s, Inc. _ Com� 7. Location where nts wer GLSD _ Sid ---re of Hauler �-------- Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc• 11112 System Pumping Record •Page 1 of 1