HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 91 CROSSBOW LANE 7/8/2026 ❑ Commonwealth of Massachusetts Town of NoqhAndover
City/Town of
System Pumping Record JUL 15 2026
❑ V' Form 4
DRP has provided this farm for use by local Boards of Health. Othe4 e �
information must be substantially the same as that provided here. Before using this form, c Ith your
local Board of Health to determine the farm 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: <6ack
a
rear I e rig h
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer,
use only the tab
key to move your Address bo
cursor-do not MA_
use the return key. City(Town _-- —� --- --- — State— Zip Code ---
2. System Owner:
----" yy
Name
Address (if different from location)
_ MA_
City(Town ------- State -- - —❑-_' Zi_p Code __—.____—'❑
Telephone Number
B. Pumping Record
1. Date of Pumping Qa❑ --------- 2. Quantify Pumped: Gallons
3. Component: ❑ Cesspool(s) ptic 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,
5. ystem Pumped By:
Dave Tine Mass 1AA95E Mass 1AD31Z
Name Vehicle License tuber
Bateson Enterprises, Inc.
(GLSD
ompany
7. ocation wh contents were disposed:
_
Signature of Hauler — Date --
Signature of Receiving Facility(or attach facility receipt) Date
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