HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 55 PHEASANT BROOK ROAD 6/15/2026 Commonwealth of Massachusetts Town of Not)Andover
City/Town of
-
.M. System Pumping Record JUL 6 2026
5 Form 4
Hea"I De up
DEP has provided this form for use by local Boards of Health. Other forms may be eR,iggIpp t
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. — 11 -
HOUSE: —4ront Cba�ide rea��e--, right
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 b019a5-.010 �- --
key to move your Address
cursor-do not
use the return key. City/Town State Zip Code
2. System ner:
Name
Address(if different from location)
MA
City/Town State
st 9
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) P_Se0i'c Tank F] Tight Tank ❑ Grease Trap
Ej Other(describe):
4. Effluent Tee Filter present? [] Yes Igo If yes, was it cleaned? F Yes M No
5. Observed condition of component pumped:
6 S y tem-:y tem Pu ped By:
D ve Tine MasslAA95E Mass 1AD31Z
Na e Vehicle License N mber
Bateson Enterprises, Inc._
r mpany
7, ocation where re ispos'60:
LSD
signature of—Hauler Date
-Signature of Receiving facility—(or attach facility -Date
t5form4.doc-11112 System Pumping Record-Page 1 of 1