HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 143 DUNCAN DRIVE 6/29/2026 Commonwealth of Massachusetts 'Own of North Andover
City/Town of
SystemPumping P u m i n Record JUL - 6 2026
Form 4
HealthDe �'nt
DEP has provided this form for use by local Boards of Health. Other farms may be used 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.
HOUSE: front ck)side rear left °`right
A. Facility Information
BUILDING: front back side rear left right
Important:When DECK: under
g y Location:
p
on the computer,
use onlyy e the t l (b ° l f x
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key to move your Address _..._.--------
cursor-do not _— ? MA
use the return ---. --- .-__ ______. _ ________
key. City/Town State Zip Code
2. System Owner: -
t^
Name
V
Address(if different from location)
MA
CitylTown State Zip Code
G.
Telephone Number
B. Pumping Record
1. Date of Pumping aaie __ ...—_._.___.___ 2. Quantity Pumped: Gallons
3. Component: Cesspool(s) Septic Tank 7 Tight Tank ❑ Grease Trap
❑ Other(describe): —.__ _..._____.____.__. __..____.__.____
4. Effluent Tee Filter present? �Yes ❑ No If yes, was it cleaned? �,D sN ❑ No
5. Observed condition of component pumped:
6. ystem Pumped By:
ave Tiney� Mass 1AA95E ass 1AD31Z _
me Vehicle License Numb r '
Bateson Enterprises, Inc.
Company
7. 1bcation where contents were disposed:
GLSD
Signature of Hauler .____._... 'bake
Signature of Receiving"Facility(or attach facility receipt) Date
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