HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 52 LACONIA CIRCLE 6/16/2026 *r_.
Commonwealth of Massachusetts Town of North Andover
City/Town of
JUL - 6 2026
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 th@,pq' 7e4):l ht
Tping date in
accordance with 310 CMR 15.351
HOUSE: ron
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-Qt❑ side reaA. Facility Information BUILDING: fro"n"tback side rear lefit right
Important:When DECK: under
filling out forms 1. Sy�ter L on:
on the computer, gg ati i
use only the tab
key to move your Addr y
cursor-do not MA
use the return City/Town State Zip Code
key.
2. Sy stem Owner:
VQ L
Name
Address(if different from location)
MA
City/Town State ode
Ye-,WPIR-0-n-e❑Num6Wr
B. Pumping Record
L $
-bate _— Gallons
1. Date of Pumping 2. Quantity Pumped:
3. Component: Cesspool(s) c Tank El Tight Tank 7 Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? F-1 Yes No If yes, was it cleaned? M Yes [] No
5. Observed condition of compopent P d,
V
6, y4em Pumped By:
D, Mass `IAA 5 Mass 1AD31Z
Name vehicle icens umber
Batesciff"Sterprises, Inc.
Company �
7. cation where s wer posed:
,
GLSD
-§719—caiure-of-Hauler Date
Signature of �ivinj��Faii:;il Facility attach facility Date
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