HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 624 BOXFORD STREET 7/13/2026 Town of Nori`) Andover
Commonwealth of Massachusetts
JUL 15 2026
City/Town of
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, 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' r�(-I right
A. Facility Information BUILDING: front back side rear right
Important:When DECK: under
filling out forms 1. System Location:
on the computer, -A
use only the tab
key to move your Address
cursor-do not A AA MA
use the return City/Town State Zip Code
key.
4- 2. System Owner:
Name
Address(if different from location}
MA
CityfTown State .Zip
-te-14-p-h-one Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Rations
3. Component: ❑ Cesspool(s) 911115eptic Tank 7 Tight Tank 7 Grease Trap
❑ Other(describe):
4, Effluent Tee Filter present? 0 Yes P--�No If yes, was it cleaned? M Yes D No
5. Observed condition of component pu ped:
6. System Pumped By:
Dave Tinev Mass 1AA95E Mass 1AD31Z
Name Vehicle License Number
Bate,W Enterprises, Inc.------
7C�&Fn p a n-y
7. Location wheg-contents Were disposed:
GLSD,"
Signature of Ha er" Date
Signature of Rece IngIF;icility(or attach facility -Date
t5form4.doc- 11/12 System Pumping Record-Page I of 1
a