HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 101 COLONIAL AVENUE 7/7/2026 Tern of North Andover
L Commonwealth of Massachusetts
LL =-FoCity/Town of JUL 15 2026
µ - _
:- System Pumping Record
-v Farm 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. -____ w____.__--
HOUSE:1 front ack side rea l:eft:N ht,,,
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out farms 1. System Location:
on the computer,
use only the tab T� V _--
key to move your Add- "
cursor-do not _MA__ _ r
use the return Gky/1 own _ —_ _____----_-_�__ _.._ State Zip Code
key.
ra/'U'g
2. System Owner:
(11 Name
Address(if different from location)
MA _
__. ...._. r"_ .__.ip Co__.___..._.______.__.___..
y p Cade
Cit i'I'own State Zi
i"elephone Number
B. Pumping Record
1. Date of Pumping — -- ---- 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): —__.____�_ __ ___ _.._. ____ ___ __ ._____.__._._._..._..__
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped,
6. System Pumped By:
m
Dave Tined Mass 1AA95E Mass 1AD31Z
Name Vehicle License Nu
Bateson Enterprises, Inc.
Company
7. QLn where contents were~ dispersed:
__._---_._
,
Signature of Receiving Facility(or attach facility receipt) Date
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