HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 91 FULLER ROAD 6/23/2026 Commonwealth of MaSS2chUsetts Town of Nofth Andover
cr City/Town of
JUL - 6 2026
System Putn in R t F y p Record
Form 4 Health
Department
DFP has provided this forrn for use by local Boards of Health, other forms may be used, but the
information must be substantially the sarne as theft providers here. Before using Ihis form, check with yr.lur
local Board of Health to determine the form they use. The system Pumping Record rnust be subrnitted to
the local Board of Health or other approving authority �.,vithin 14 days from the purnping date In
accordance with 310 CMR 15,351 ___..._u__. _ 0�ro
HGUS�: hat k slcir� rr2rr lr�.f right A. Facility Information BUILDING: back side rear Ieft right
Important: When DECK: under
or iny out forms 1, System Location
].t
on the computer,
use only the tab
key to move your Addre s
Cursor-do not MA �/
use the return �""". .. __._— _ __.____ 1_...1 -. __.._.3.) ° ^'-----------
key.
ity[Fown State Zip Code
r" 2. System owner.
R c'' �r
Name
Adclrc3ss (if differen( from locatlpn)
MA
Gity(Town slat>. Zip Code
Telephone f,4ornk)er
B. Pumping Record
1. Date of Pumping . - 2 quantity Purnped --
Ca1e Gallons
3, Component: El cesspool(s) ( Septic Tank 'right❑ 'ric Tank} � Grease Trap
(� Other (describe): _
4. Effluent Tee Filter present? C Yes No If yes, was it cleaned? Ll Yes r�o
----__--
J. Observed condition of c orltpcnent purnped
6. System Pumped By:
Dave TIneY Mass 1AA95E ass 1AD317_
Name VP=hIclt, t_iren;,4 Ntirr'i er
Bateson Enterprises Inc
Cornpany
7. " ion where contents were disposed,
LS
gn lure r iauler Date
Signature of Receiving Facility (or attach facility receipt) Cafe _---
t5form4.doc- 11112 System Pumping Record • Pigr:, 1 of 1