HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 116 BRIDGES LANE 6/19/2026 Commonwealth of Massachusetts Town of Nor�h Andover
City/Town of
System Pumping Record JUL -6 2026
Form 4
Heal"I De
DEP has provided this form for use by local Boards of Health. Other forms m.MC4ppat 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 the pumping date in
accordance with 310 CIVIR 15.351.
2;\ .
HOUSE: ron back side rear e h
A. Facility Information BUILDING: C21 back side rear left right
Important,When DECK: under
filling out forms 1. System Location:
on the computer,
use only the tab j � (0
key to move your Address
cursor-do not
use the return MA
key. City[Town State Zip Code
2. S�yern Owner:
Name
Ell-']'=112
Address(if different from location)
-MA
City/Town State ip ode
-telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component: 7 cesspooi(s) <:J—optic Tank 7 Tight Tank 7 Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? D Yes o If yes, was it cleaned? F Yes ❑ No
5. Observed condition of compon4enpumped-
"6
6. stem limped By:
Dave T1 e Mass 1AA95E Ma 1 rAD31 Z
Name
�'s m e Vehicle License Number
Bateson Enterprises, Inc.
Company
7. ocation e C disposed:
GLSD
Signature of Hauler Date
Signature of Receiving'Facility(or attach facility receipt) Date
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