HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 149 BRIDGES LANE 6/15/2026 Commonwealth of Massachusetts Town of North Andover
City/Town of
System Pumping Record JUL - 6 2026
Form 4
DEP has provided this form for use by local Boards of Health. Other for4444 PkpadrAent
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.
left—right
HOUSE: front ba side rear left r
si c�s c
front
(ql�t
A. Facility Information BUILDING: front ack side rear left
Important:When DECK: under
filling out forms 1. System Location:
on the computer, ( I d q
use only the tab L�
key to move your Address
cursor-do not
MA
use the return
key. City/Town State Zip Code
2. System Owner:
6/ -------------
Name
Address(if different from location)
MA
City/Town State Zip Code
— __m__µ_❑_
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component: F� Cesspool(s) /Septic Tank F-1 Tight Tank 7 Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? D Yes o If yes, was it cleaned? F Yes M No
5. Observed condition of component pumped'.
6. S stem P'IV mped By:
ave Tin Mass 1AA95EZ'�1 1 Mass 1AD31Z
N a Vehicle Licens7ber
Bat E er rises, Inc.
Company--
7. ation h ere ents were"disposed:
,
Signature of
Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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