HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 11 BARCO LANE 7/17/2026 Commonwealth of Massachusetts lbwn of Norch Andover
City/Town of
JUL 2 7 2026
System Pumping Record
Form 4 Flea"I Departmqg
DEP has provided this form for use by local Boards of Health. Other forms may be used, bu
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 pum Ing date in
accordance with 310 CMR 15.351. 7-'1
-fro n; right .
HOUSE: back side rear -�e`ry " �
A. Facility Information BUILDING: fro ba ' side rear Ie+-M5h1r1"
Important:When DECK: under
filling out forms 1. S t cation:
on the computer, III use only the tab rnx)
key to move your Ad6ress' -- '
cursor-do not /AJ MA
use the return City/Town State Zip Code
key.
2. Syste Owner:
Ff
Name
few
Address(if different from location)
MA
City[Town State/ �
Telephone 111U1THJt:!1
B. Pumping Record
1. Date of Pumping Date 7� ( l 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) J2,8,eptic Tank 7 Tight Tank ❑ Grease Trap
❑ Other(describe):
4, Effluent Tee Filter present? Fj Yes E,TNo If yes, was it cleaned? ❑ Yes 7 No
5. Observed condition of component pumped* ❑
6, Sy tf Pumped By: ❑
Dave Tjne Mass lAA95E ass 1AD31Z
Name Vehicle License Nu er
ateson_Fir�erprises, Inc.
7. Location wh r conga. were disposed;--"/
D
Signature of Hauler Date
Signature of Receiving'Facility(or attach facility receipt) Date
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