HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 40 EQUESTRIAN DRIVE 7/7/2026 Commonwealth of Massachusetts Town of Nofth Andover
City/Town of
S System Pumping Record JUL 1 5 2026
Form 4
DEP has provided this form for use by local Boards of Health. Other UA9'Ay9eqRAr,09Qt
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.
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HOUSE: on ack side rear le right
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A. Facility Information BUILDING: back side rear left r
Important;When DECK: under
filling out forms 1. System Location:
on the computer, 4]
use only the tab
key to move your Acldre s
cursor-do not Aj MA
use the return
key. CityfTown State Zip Code
2. (y SyT Owker;ti
.,
Name
WS
Address(if different from location)
MA
lty(Town State Zip Code
Telep ..4u
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Alons
3. Component: ❑ Cesspool(s) �epfi c Tank 7 Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? [] Yes No If yes, was it cleaned? 7 Yes F1 No
5. Observed condition of component mped:
7r,
oe--ury
Syst�t Pumped By:
Dave Tiney...... -Mass 1 AA9_ Mass 1AD31Z
Name Vehicle License rqbw-�2r
Bateson Enterprises,
_C�,orn p a n�
7. Location V� conten were disposed:
GL
I nature of Hauler Date
-Signature of-Receiving--Facility—(or attach facility--receipt)---- -bate
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